Abdomen and Musculoskeletal Documentation Obtain the following information on an adult volunteer. For the history, ask about the items indicated. For the physical exam items; read the assigned chapters, review the course presentations/videos, and gather needed equipment before performing the exam. Use this guide when documenting the findings.
Be sure to address all items in your documentation. Gender, age, birthplace, race/ethnicity Abdomen, musculoskeletal 0
Past medical history – Personal history of acute/chronic disease, surgery, injury, infection, pain a Review of systems 0 Abdomen – Appetite, intolerance to any food, heartburn, nausea, vomiting, constipation, diarrhea, change in stool, incontinence, bleeding, hemorrhoids, laxatives, endoscopic tests and results
0 Musculoskeletal – Pain, stiffness, swelling of joints, limited movement, cramps, weakness, problem with gait, deformities, assistive devices 0 Family history of illnesses in these systems Abdomen Inspect – skin, umbilicus, peristalsis, symmetry, aortic impulse, etc. Auscultate — bowel sounds Percuss – general Palpate — light, aortic pulse, deep, liver, kidneys Costovertebral angle (CVA) tenderness – can do here if not already done with posterior chest Musculoskeletal 0 Inspect— muscularity, symmetry, alignment, deformities, edema, redness, etc. 0 Neck 0 ROM – flexion, hyperextension, rotation, lateral bending 0 Strength