Writing Up the Physical Examination

Listed here are examples of the write-up for the examination of the abdomen.

• The abdomen is scaphoid without scars. Bowel sounds are present. The liver is felt 2 fingerbreadths below the right costal margin for a total span of 10 cm [4 inches]. Neither the spleen nor any masses are felt. The kidneys are not palpable. Rectal examination reveals normal sphincter tone. The prostate is soft, without any masses. The walls of the rectum are smooth, without masses. Results of testing of the stool for blood is negative. No costovertebral angle tenderness [CVAT] is present.

• The abdomen has a scar in the right upper quadrant. Bowel sounds are absent. Marked tympany is present throughout the abdomen. Rigidity is present throughout. Marked tenderness is present in the abdomen, especially in the left lower quadrant. Examination of the rectum reveals tenderness in the same area. Stool guaiac test result is 4+. The liver, spleen, and kidneys are not felt. No CVAT is present.

• The abdomen is obese. Bowel sounds are present. Percussion notes are normal. There is an area of significant pain in the right lower quadrant, immediately above the right midposition of the inguinal ligament. Rectal examination discloses severe pain in the same area. The obturator and straight leg raising signs are positive on the right. Stool guaiac test result is negative. Right CVAT is present. No organomegaly is felt.

• The abdomen is protuberant, with a midline well-healed scar. Bowel sounds are present. Shifting dullness and a fluid wave are present. A large mass 8 x 15 cm [3 x 6 inches] is felt in the right upper quadrant. Results of examination of the rectum are unremarkable except for a trace positive stool guaiac. There is no hepatosplenomegaly.

• The abdomen is scaphoid and soft, without guarding, rigidity, or tenderness. Bowel sounds are present. The liver measures 12 cm [4.7 inches] in span in the midclavicular line. The spleen tip is felt below the left costal margin. No masses are present. Rectal examination reveals a 2-cm [0.75-inch] hard nodule in the posterior lobe of the prostate, which is nontender. Stool guaiac test result is negative.

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