Redness denies Misalignment denies Other Click or tap here to enter text

Redness denies misalignment denies other click or tap

This preview shows page 5 - 9 out of 12 pages.

Redness - denies Misalignment - denies Other: Click or tap here to enter text. Nausea/Vomiting - denies Dysphasia - denies Diarrhea – one episode 2-3 days ago Appetite Change – decreased appetite past couple of days due to abdominal pain Heartburn - denies Blood in Stool – denies Abdominal Pain - cramply, dull; the whole abdomen but mostly the lower; past 5 days but has gotten worse the past 2-3 days; pain aggravated by movement and eating; relieved by rest Excessive Flatus - denies Food Intolerance - denies Rectal Bleeding - denies Other: Urgency - denies Dysuria - denies Burning - denies Hematuria - denies Polyuria - denies Nocturia - denies Incontinence - denies Other: urinating slightly less than usual Stress – regarding to the stomach pain Anxiety – regarding to the stomach pain Depression - denies Suicidal/Homicidal Ideation - denies Memory Deficits - denies Mood Changes - denies Trouble Concentrating - denies Other: Click or tap here to enter text.
Image of page 5
Click or tap here to enter text. GYN Rash - denies Discharge - denies Itching - denies Irregular Menses – N/A Dysmenorrhea – N/A Foul Odor - denies Amenorrhea – N/A LMP: N/A Contraception - denies Other: menopause at age 54 Body System Positive Findings Negative Findings General Choose an item. Click or tap here to enter text. Alert & oriented Dressed appropriately Skin Choose an item. Click or tap here to enter text. No tenting HEENT Choose an item. Click or tap here to enter text. Skull and facial features symmetrical Nasal mucosa moist and pink Oral mucosa moist and pink O: Objective Information gathered during the physical examination by inspection, palpation, auscultation, and palpation. If unable to assess a body system, write “Unable to assess”. Document pertinent positive and negative assessment findings.
Image of page 6
Respiratory Choose an item. Click or tap here to enter text. Breath sounds in all areas No adventitious sounds heard Neuro Choose an item. Click or tap here to enter text. Click or tap here to enter text. Cardiovascular Choose an item. Click or tap here to enter text. No edema in bilateral lower extremities S1 and S2 audible No extra heart sounds Musculoskeletal Choose an item. Click or tap here to enter text. Click or tap here to enter text. Gastrointestinal Choose an item. Scarring on lower abdomen Tenderness reported on light palpation - left lower quadrant Guarding and distention reported on light palpation Abdomen symmetrical and flat No bruit in abdominal aorta Normoactive bowel sounds in all quadrants
Image of page 7
Deep palpation - palpable mass in left lower quadrant Fecal mass in rectal vault in digital rectal exam No bruit in bilateral renal arteries No bruit in bilateral femoral arteries No bruit in bilateral iliac arteries No friction rub upon auscultation for liver and spleen Upon percussion, some areas dull and some tympanic Spleen tympanic upon percussion Liver span between 6-12 cm Pt did not react to CVA tenderness Aortic width 3 cm or less Liver palpable Spleen, bladder, and bilateral kidneys not palpable Genitourinary Choose an item.
Image of page 8
Image of page 9

You've reached the end of your free preview.

Want to read all 12 pages?

  • Fall '15
  • Crohn's disease, Bowel obstruction, Human abdomen

  • Left Quote Icon

    Student Picture

  • Left Quote Icon

    Student Picture

  • Left Quote Icon

    Student Picture

Stuck? We have tutors online 24/7 who can help you get unstuck.
A+ icon
Ask Expert Tutors You can ask You can ask You can ask (will expire )
Answers in as fast as 15 minutes