CHAPTER 21
Abdomen
195
REGIONAL WRITE-UP—ABDOMEN
Date ________________________
Examiner ____________________
Patient _________________________________________________ Age _________ Gender _________
Reason for visit _______________________________________________________________________
I. Health History
No
Yes, explain
1. Any change in appetite? Loss?
2. Any difficulty swallowing?
3. Any foods you cannot tolerate?
4. Any abdominal pain?
5. Any nausea or vomiting?
6. How often are bowel movements?
7. Any past history of GI disease?
8. What medications are you taking?
9. Tell me all food you ate in the last 24 hours, starting with:
breakfast
snack
lunch
snack
dinner
snack
II. Physical Examination
A. Inspection
Contour of abdomen ______________________ General symmetry _______________________
Skin color and condition __________________________________________________________
Pulsation or movement ___________________________________________________________
Umbilicus ______________________________________________________________________
State of hydration and nutrition ____________________________________________________
Person’s facial expression and position in bed __________________________________________
B. Auscultation
Bowel sounds ___________________________________________________________________
Note any vascular sounds. _________________________________________________________
C. Percussion
Percuss in all four quadrants. _______________________________________________________
Percuss borders of liver span in R MCL. _________________ cm
Percuss spleen. __________________________________________________________________
If suspect ascites, test for fluid wave and shifting dullness. ________________________________
D. Palpation
Light palpation in all four quadrants
Muscle wall __________________________ Tenderness ______________________________
Enlarged organs _______________________________________________________________
Masses ______________________________________________________________________
Deep palpation in all four quadrants
Masses ______________________________________________________________________
Contour of liver ___________________________ Spleen _____________________________
Kidneys _______________________________Aorta _________________________________
Rebound tenderness ___________________________________________________________
CVA tenderness _______________________________________________________________
Jarvis, Carolyn: PHYSICAL EXAMINATION AND HEALTH ASSESSMENT: Seventh Edition,
Laboratory Manual. Copyright © 2016, 2012, 2008, 2004, 2000, 1996 by Saunders, an imprint of Elsevier Inc. All rights reserved.