Abdominal Assessment Write-Up and Documentation
The abdominal assessment was done on a 28-year-old Caucasian male.
Consent: A verbal informed consent was obtained from the patient before beginning the assessment process. The client consented to have the examination, a video of the assessment process captured, and the video uploaded on YouTube for educative purposes. The link to the video is https://youtu.be/wXXzRRN3dFM.
Abdominal Examination
- The objectives of the abdominal assessment process are to demonstrate, in-depth, the procedures entailed in a physical examination of the abdomen, to detail the exam findings, and to determine how they can inform a diagnosis.
- Before initiating the assessment process, the patient must acclimatize to the assessment environment.
- The patient’s biodata and subjective history are then obtained to inform specific body areas requiring special considerations during the physical examination as well as the body systems that may be involved in the presenting complaints.
- Informed consent is obtained before beginning the assessment process.
- Obtaining informed consent is necessary as it is aligned with the provisions of autonomy that grant patients authority over critical decisions regarding their health (Varkey, 2020). It also demonstrates respect for the patient.
Inspection
The patient assumed a supine position, with the head and knees supported by a pillow and the abdominal musculature relaxed. Visual examination revealed a well-rounded and symmetrical abdomen. No abdominal bulging or distension was noted during visual inspection. The skin on the abdominal wall was consistent in coloration with no surgical scars, striae, bruising, scars, skin lesions, discoloration, abdominal wall mass, or rash seen on visual inspection. There were also no signs of vein engorgement on the patient’s abdominal wall.
Auscultation
No rumbling, gurgling, or growling sounds on the auscultation of the four abdominal quadrants. There were also no bruit sounds on the auscultation of the abdominal area around the aorta, iliac, and femoral arteries.
Percussion
Tympanic sounds were heard in all of the four abdominal quadrants. The patient denied experiencing any tympanic tenderness on percussion. There were no dull sensations felt over the right lower quadrant. The span of the liver measured seven centimeters from the mid-clavicular line and four centimeters from the mid-sternal border. Percussion of the spleen revealed no dullness. No tympanic sounds were felt on percussion of the upper lateral abdominal side when the patient was asked to shift to the lateral position.
Palpation
Palpation of the abdomen revealed no abdominal tenderness or masses across the four quadrants. The patient also denied feeling any abdominal pain or tenderness during light and deep palpation. No abdominal masses were felt on deep palpation of the abdomen. The border of the liver was felt when palpating it. The patient denied feeling any pain or tenderness during palpation of the liver. The spleen was not felt when palpating. There were also no signs of a well-rounded abdominal bulging, symmetrical contours, or a bulging flanking on evaluation of ascites. No dull sounds were felt on
Other Tests
Fluid Wave Test
- No fluid movement or impulse was felt when touching the opposite side of the abdomen.
Murphy’s Sign
- The patient denied any pain sensation on palpation of the right subcostal area after a deep inspiration.
McBurney’s Point Test (Rebound tenderness test)
- The patient denied any sensation of severe pain upon pressure application on the lower abdominal quadrant around McBurney’s Point.
Costovertebral Angle (CVA)
- The patient denied experiencing any pain sensation or tenderness on the costovertebral angle on percussion.
References
Varkey, B. (2020). Principles of clinical ethics and their application to practice. Medical Principles and Practice, 30(1), 17–28. https://doi.org/10.1159/000509119
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Question 
Abdominal Examination
Objectives:
- Describe in detail the procedures involved in an abdominal examination.
Abdominal Assessment Write-Up and Documentation
- Explain the significance of examination, auscultation, percussion, and palpation in determining abdominal function.
