NCM 1234: HEALTH ASSESSMENT (RLE)

ABDOMEN

Name: Section: Date:

Name of Patient: Age: Gender:

HEALTH HISTORY
ASSESSMENT No Yes, Explain

1. Any change in appetite? Loss?

2. Any difficulty in swallowing?

3. Any foods you cannot tolerate?

4. Any abdominal pain?

5. Any nausea or vomiting?

6. How often are your bowel

movements?

7. Any past history of GI disease?

8. What medications are you taking?

9. Tell me all the food you ate in the last 24 hours, starting with:

Breakfast

A.M. snack

Lunch

P.M. snack

Dinner

Midnight snack
PHYSICAL EXAMINATION
INSPECTION
Contour of abdomen

General Symmetry

Skin color and condition

Pulsation or movement

Umbilicus

Hair distribution

State of hydration and nutrition

Person's facial expression and position in bed

AUSCULTATION
Bowel sounds

Note any vascular sounds

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

PALPITATION
A. Light palpitation in all four quadrants

Muscle wall

Tenderness

Enlarged Organs

Masses

B. Deep palpitation in all four quadrants

Masses

Contour of liver

Spleen _

Kidneys

Aorta
 Rebound Tenderness

CVA (costovertebral angle) tenderness

Summarize your findings below:

The patient denies abdominal pain, nausea, vomiting, bloating, constipation, diarrhea, urinary pain, urgency or frequency, change
in appetite, food intolerance, dysphagia, or personal or family history. Abdominal contour is flat and symmetric. No visible lesions,
pulsations, or peristalsis noted. Bowel sounds present and normoactive. Patient denies pain with palpation; no masses noted.

Source: Udan, Josie (2009). Health Assessment and Physical Examination: Concepts and Clinical Application