Abdominal exams- this one is a rush!

Get used to the timings with this one- its hard to squeeze in.

Observation
1. wash hands
2. Hello, my name is X, im a first year medical student
3. can i check your name and age please? DOB
4. Would it be ok for me to examine your abdomen?
5. Do you have any pain/ nausea / vomiting
6. Do you mind if i expose your stomach
7. "Patient looks well with normal palour"
8. Have you lost any weight recently Mr X? "no signs of malnutrition"
9. no signs of scars, spider naevi, swelling, distention or dilated veins
10. Have you had any abdominal surgery?
11. there is no visable organomegaly or peristalsis
12. im going to just have a general look at you before i concentrate on your stomach

Hands
1. No clubbing, spooning, leuonchyia or dupuytren's contracture
2. No signs of palmer erythema and hands are a normal temperature
3. please can you hold your hands up and put your hands back
4. no sign of CO2 retention

Pulse
1. Pulse is regular and strong in character

Neck
1. No inflammation of the lymph nodes

Face
1. No anaemia, jaundice or corneal ulcer
2. Dental hygeine is good. There is no central cyanosis, angular stomatis or ulcer. No sign of candida infection.

Palpation
1. Do you have any pain in your abdomen? can you point to it please?
2. I will be appling some pressure, please let me know if its uncomfortable
3. Kneel at patient level, maintain eye contact
4. On palpation the abdomen shows no gaurding or rebound tenderness. No sign of organomegal or palpable masses
5. Can you take a breath in please, when i say
6.No signs of hepato or spleno megaly
7. no sign of aortic aneurism
8. please culd you lift yourself up slightly and cough "no abnormality in hernia areas. To increase the accuracy of this examinationi would ask the patient to stand and examine the hernial orcus"

Percussion
1. Hepatic dullness and gastric resonance were normal
2. im going to assess for fluid in the abdomen
3. can you roll onto your left side please (should remain resonant)
4. I would wait for 10 seconds to allow any fluid in the parietal cavity to move
5. no sign of shifting dullness
6. No fluid thrill

Ausculation
1. On auscultation bowel sounds are present with no abnormal sounds
2. there is no aortic renal or inguinal bruits

Cover patient and thank
To complete the abdominal examination i would do a rectal and external genatalia examination and a urinalysis

Summary
Mr X has presented for a routine abdominal exam. On general inspection he is no visable pain or discomfort, he is breathing normally. No sign of palour or distention. No swelling, visable organolmegaly or peristalsis. He has no peripheral stigmata that would suggest any abdominal pain.

On palpation there was no gaurding or rebound tenderness, and no palpable masses. No sign of organomegaly or aortic aneurism. On percusson everything is normal, with hepatic dullness and gastric responce. No shifting dullness or fluid thrills. Bowels sounds are normal and there are no arterial bruits.


taaadaaaa Jazz hands etc