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Learning Issue: Document Abdominal Exam Findings Name: Rachel Chacko Example: Abdomen: Nondistended, no tenderness to palpation. Bowel sounds were present bu hypoactive. No masses were palpable. The liver span percussed to 8 cm and the edge was smooth and palpable 2 cm below the right costal margin. The spleen was not palpable. From: Mosbys, Page 812 Example: Gastrointestinal: Examination of abdomen with notation of presence of masses or tenderness (GI: "abdomen soft, non-tender w/o organomegaly or masses; bowel sounds WNL*; no guarding or rebound tenderness"); Gastrointestinal: Examination of liver and spleen (GI: "abdomen soft, non-tender w/o organomegaly or masses"); *Within Normal Limits From: American Academy of Family Physicians
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Unformatted text preview: http://www.aafp.org/online/en/home/publications/journals/fpm/collections/fpmmedicare/examdo c.html Physical Examination Findings (Things you should be looking for) ● Shape, contour, visible aorta pulsations, surface motion, venous patterns, scars, hernia or separation of muscles, peristalsis ● Auscultation findings: presence and character or bowel sounds in all quadrants, friction rub over liver or spleen ● Palpation findings: aorta, organs, feces, masses; location, size, contour, consistency, tenderness, muscle resistance ● Percussion findings: tone in each quadrant, areas of different percussion notes, costovertebral angle (CVA) tenderness, liver span From: Mosbys, Page 804...
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