Regional Write-Up Abdomen

REGIONAL WRITE-UP ABDOMEN

SUBJECTIVE:

Health History: B.C is a 21 year-old female nursing student here for Quarterly check-up. Denies any change in appetite, difficult swallowing, or food intolerance. She also denies any abdominal pain, nausea or vomiting, and any history of GI disease. Report bowel movement once a day, and denies taking any medication. On the last 24 hours food intakes; she report taken Ham sandwich for breakfast, chicken enchilada and cookies for lunch, and chicken with rice for dinner.

OBJECTIVE:

General Survey/Mental Status: B.C awake, alert, and oriented to person, place and time. (A & O X 3). Appears stated age. Wear neat scrub appropriate for Lab. No apparent distress, weight appears within normal range for her height and body build. Appears well nourished. Hair is evenly distributed; black, soft and wavy. Skin color shows even pigment, no lesion. Sitting on exam bed, speech clear and understandable.

Physical Examination: Inspection: abdominal muscles flat with slight rounding, no contour, bilaterally symmetry, and the skin color is pink-tan, no straie, smooth and intact. No observable pulsation or movement, umbilicus is invert, no discoloration, inflammation, or crust. Pt. appears well hydrated and well nourished, facial expression was pleasant, no sign of pain or grimacing. Auscultation: active bowel sound in all the four quadrants (LRQ, URQ, ULQ and LLQ), no murmur or bruit present. Percussion: tympany present in all the four quadrants. Palpation: stomach muscle wall firm and smooth, no excess adipose tissue above the pubic or hypo-gastric area, no tenderness, and no enlarge organ palpated, and no masses.