Terms in this set (35)

Original
Inspect-Abdomen
Symmetry: Symmetric
Contour: Protuberant
Appearance: Striae
Excessive hair growth

Auscultate-Bowel Sounds
Sounds: Normoactive
Location of Non Normoactive Bowel Sounds: all quadrants normoactive

Auscultate- Abdominal Aorta
No bruit

Auscultate- Abdominal Arteries
Right Renal: No bruit
Right Iliac: No bruit
Right Femoral: No bruit

Left Renal: No bruit
Left Iliac: No bruit
Left Femoral: no bruit

Percussion-Abdomen
All areas are tympanic

Percussion-CVA Tenderness
Did not react

Percussion-Liver Span
Between 6 and 12cm

Palpate-Light
Tenderness- No Tenderness
Location of Tenderness- No quadrants tender
Observations- no additional observations

Palpate- Deep
Presence of Unexpected Mass-No palpable mass
Location of Mass-No palpable mass

Palpate-Liver
Detection-Palpable

Palpate-Spleen
Detection-Not palpable

Palpate-Kidneys
Right- Not palpable
Left- Not palpable

Relevant Medical History +2
When was your last bowel movement?

Family History +1
Any family history of abdominal conditions?

Family History +1
Any family history of abdominal cancer?

Relevant Medical History +1
Have you had any stomach aches?

Relevant Medical History +1
Have you had any diarrhea?

Relevant Medical History +1
What does your stool look like?

Relevant Medical History +2
How often do you go to the bathroom?

Relevant Medical History +1
How often do you eat?

Relevant Medical History +1
Do you have any pain after meals?

Relevant Medical History +1
Do you have any pain going to the batrrom?

Relevant Medical History +1
Are there any foods that cause you pain?

Relevant Medial History +1
Do you ever throw up?

Review of Systems +1
Have you ever had an appendectomy?

Relevant Medical History +1
Do you have any nausea?

Relevant Medical History +1
How much water do you drink?

Risk Factors +1
Do you smoke?

Risk Factors +1
Do you drink alcohol?

Risk Factors +1
Do you use illicit drugs?

Relevant Medical History +1
Do you get hungry often?

Relevant Medical History +1
Do you urinate normally?

Relevant Medical History +1
Is your urine cloudy?

Review of Systems +1
How did you loose your weight?

Document Additional Findings
Patient denies any digestive problems.
Patient denies reflux, nausea, dysphagia, constipation, diarrhea, changes in bowel habits, jaundice, abdominal pain, or bloody stool.
Patient denies pain upon voiding.
Patient voids regularly, and claims normal stool color and shape.
Patient denies any gallbladder or liver disease. Patient denies any kidney disease or history of kidney stones.
Patient reports increased polyphagia and polydipsia.
Patient reports drinking 3-4 diet cokes per day.