Week 5 Assignment 1: Skin and Abdomen Video Assessment

Please only write subjective findings of skin and abdomen. Normal findings only. This is for the video assessment of skin and abdomen that I have done in normal patients.

SUBJECTIVE (15%)

Documentation: (15)

The NP student documents subjective (S) components of SOAP Note:

Normal findings for subjective history (ROS) of focus system(s) (10)

Documentation in the correct format:

The findings should all be normal and must include findings across the lifespan. The subjective history is only needed for the age group.

Skin/Hair/Nails 

 

__/5 points: Inspect skin characteristics including moisture, dryness, temperature

__/1 point: Identify lesions noting location, distribution, and characteristics

__/2 points: Inspect and palpate scalp and hair for lesions, texture, distribution, and quantity, and any pattern of loss

__/2 points: Inspect nails for clubbing and cyanosis

Abdomen (35 points)—the patient should be positioned supine, knees bent, head supported and arms at the side

__/1 point: Inspect the abdomen for symmetry, characteristics, contour, scars, striae, rashes, lesions, pulsations, movement, and bulges

__/4 points: Auscultate all quadrants for bowel sounds noting frequency and character

__/4 points: Auscultate aorta, iliac, renal, and femoral arteries noting any bruits and over the liver and spleen for venous hums or friction rubs

__/6 points: Percuss all quadrants noting tympany or dullness

__/2 points: Percuss lower anterior chest above the costal margin noting dullness of the liver, percuss border, and estimate liver span

__/1 point: Percuss at an anterior axillary line at lowest interspace and ask the patient to take a deep breath to assess for splenomegaly

__/8 points: Lightly palpate all quadrants noting tenderness, muscle resistance/guarding, or superficial masses, and pulsation

__/8 points: Deeply palpate all quadrants to identify the liver edge, kidneys, tenderness, and abdominal masses

__/1 point: Assess for CVA tenderness

Special Techniques (5 points)

__/1 point: Identify a correct location for McBurney point (just below the middle of a line joining the umbilicus and the anterior superior iliac spine)

__/1 point: Palpate for a Rovsing sign and referred rebound tenderness (pain in the RLQ during left-sided pressure)

__/1 point: Assess for a positive psoas sign (press hand above the patient’s right knee and ask the patient to raise that thigh against your hand)

__/1 point: Assess for a positive obturator sign (flex patient’s right thigh at the hip, with the knee bent, and rotate the leg internally at the hip)

__/1 point: Assess for a positive Murphy sign (palpate the liver edge and ask the patient to take a deep breath)

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