How do you document a normal abdominal exam?
Documentation of a basic, normal abdominal exam should look something along the lines of the following: Abdomen is soft, symmetric, and non-tender without distention. There are no visible lesions or scars. The aorta is midline without bruit or visible pulsation.
How would you describe a normal physical exam?
No abnormal curvature of spine. Full range of motion, no muscle spasm or tenderness. Breasts (female) symmetrical, normal size; no dimpling, masses, tenderness, or skin changes. No nipple deformity or discharge.
What are normal abdominal percussion sounds?
The anterior gas-filled abdomen normally has a tympanitic sound to percussion, which is replaced by dullness where solid viscera, fluid, or stool predominate. The flanks are duller as posterior solid structures predominate, and the right upper quadrant is somewhat duller over the liver.
What are the 6 components of a physical exam?
Terms in this set (6)
- Inspection. Is the intial part of the exam.
- Palpation. Examination by roughing with the fingers or hands. (
- Percussion. Producing sounds by tapping various parts of the body.
- Auscultation. Listening to sounds made by patient body , indirectly with stethoscope.
- Mensuration.
- Manipulation.
How should a normal abdomen feel?
A generally resonant abdomen suggests much flatus whilst solid or liquid under the fingers will be dull. Sometimes it is helpful to use percussion to define the edge of the liver. It can also be used to delineate an enlarged bladder or a tumour arising from the pelvis.
Is a soft abdomen normal?
Normal: Abdomen is soft, rectus muscle is relaxed and no discomfort is elicited during palpation.
How would you describe normal Heent?
Documenting a normal exam of the head, eyes, ears, nose and throat should look something along the lines of the following: Head – The head is normocephalic and atraumatic without tenderness, visible or palpable masses, depressions, or scarring. Hair is of normal texture and evenly distributed.
How do you document normal skin turgor?
To check for skin turgor, the health care provider grasps the skin between two fingers so that it is tented up. Commonly on the lower arm or abdomen is checked. The skin is held for a few seconds then released. Skin with normal turgor snaps rapidly back to its normal position.
What is the normal shape of abdomen?
During inspection of the abdomen, note the general shape of the abdomen, describing it as flat, scaphoid, protuberant or distended. Note the presence of bulging flanks, or focal bulges.
What does a normal abdominal exam look like?
Documentation of a basic, normal abdominal exam should look something along the lines of the following: Abdomen is soft, symmetric, and non-tender without distention. There are no visible lesions or scars. The aorta is midline without bruit or visible pulsation. Umbilicus is midline without herniation.
What should a nurse practitioner look for in a basic abdominal exam?
Here are a few basic tests nurse practitioners should know: Documentation of a basic, normal abdominal exam should look something along the lines of the following: Abdomen is soft, symmetric, and non-tender without distention. There are no visible lesions or scars. The aorta is midline without bruit or visible pulsation.
What is included in the examination of the abdomen pom?
Examination Of The Abdomen Examination Of The Abdomen POM –November 6, 2019 Charlie Goldberg, M.D. [email protected] Abdominal Exam •4 Elements: Observation, Auscultation, Percussion, Palpation •Pelvic, male genital& male/female rectalexams all criticalparts of Abdomen exam →covered later in the year GI Review of Systems
What are the elements of a general abdominal exam?
•4 Elements: Observation, Auscultation, Percussion, Palpation •Pelvic, male genital& male/female rectalexams all criticalparts of Abdomen exam →covered later in the year GI Review of Systems •http://meded.ucsd.edu/clinicalmed/ros.htm Surface Anatomy Umbillicus Supra-Pubic Area Epigastric Area Observation & Draping •Exposure →Drapefor