Example abdominal exam documentation

Bimanual Exam- uterus is anterior, midline, smooth, not enlarged, adnexa not felt Rectovaginal Exam- nl sphincter tone. Abstract: This article serves to assist the novice family nurse practitioner student in the examination of abdomen in a patient presenting with acute abdominal pain. May show, for example, angular stomatitis (which may be due to iron deficiency), thrush, signs of dehydration, ulcers, etc. Example of a Complete History and Physical Write-up Patient Name: Unit No: Location: Informant: patient, who is reliable, and old CPMC chart. Nausea and vomiting can be side effects of medications, a manifestation of many diseases, and can occur frequently in early pregnancy.

While these are the same elements which make up the pulmonary and cardiac exams, they are performed here in a slightly different order (i. While you wont use all of these elements in documenting an abnormal abdominal exam on the same patient, the following are examples of some abnormal abdominal physical exam findings you may need to note. This obstetric abdominal examination OSCE guide provides a clear step-by-step approach to examining the pregnant abdomen, with an included video demonstration. It is a very common and nonspecific complaint that can be difficult to diagnose, especially for the family nurse practitioner student.

Obstetric abdominal examination frequently appears in OSCEs and youll be expected to pick up the relevant clinical signs using your examination skills. Users outside the medical profession are welcome to use this website, but no content on the site should be interpreted as medical advice.

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