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Primary Clinical Skills: GI

GI

Documentation Examples of Abdomen:

  1. Soft, nontender, +bowel sounds in all 4 quadrants.
  2. Soft, nontender, nondistended, active bowel sounds.
  3. Tender to palpation RLQ. Mild guarding, no rebound, hypoactive bowel sounds.
  4. Rigid, no bowel sounds.
  5. Protuberant. Active bowel sounds in all 4 quadrants. Soft, nontender. No palpable masses or hepatosplenomegaly. Liver not enlarged, smooth edge. Spleen and kidneys not felt. No CVA tenderness.
  6. Flat, firm, no bowel sounds heard. Tenderness throughout with guarding present and rebound present in right lower quadrant. Liver not enlarged, edge not felt. Spleen and kidneys not felt. No CVA tenderness.