☐ 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.
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.
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
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.
- Fall '15
- Crohn's disease, Bowel obstruction, Human abdomen