# Physical exam of abdomen



## umas86 (Mar 4, 2013)

Hi,

   The physical exam in my E&M chart states that
Abdomen- soft and non distended. Tender to palpation.

I have a doubt whether can we consider this documentation as GI system or it is only a body area. Somebody help me out.


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## Kisalyn (Mar 13, 2013)

It's counted as 1 element under body area.


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## FTessaBartels (Mar 13, 2013)

*Either*

If you look at the bullets in the 1997 General Multi-System Exam you will find:

*Gastrointestinal*
 - Examination of abdomen with notation of presence of masses or *tenderness*


So, yes you can count Abdomen- soft and non distended. Tender to palpation as 1 bullet in GI system.

Hope that helps.

F Tessa Bartels, CPC, CEMC


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## MikeEnos (Mar 15, 2013)

Tessa is right, that is a finding of the Gastrointestinal system.  I strongly advise you to familiarize yourself with the 1997 exam guidelines, because they can help us non-clinicians understand what organ system the physician is examining when we wouldn't ordinarily be able to infer it.

For other resources, try searching online.  I found this blog which I found to be extraordinarily helpful.  Dr. Rob Lambert has a series of blog posts about the Physical Exam.  Here's an excerpt specifically about the abdominal exam.



> 1.    Soft
> 
> Soft is good.  At least it is good when you examine the abdomen, although not too soft.  When doctors push down on the belly of the patient, the first thing they note is the consistency.  If bad stuff is going on in the abdominal cavity, the person involuntarily tenses his/her abdominal muscles.  This is known as guarding.
> 
> ...


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## umas86 (Mar 20, 2013)

Thank you so much. I got a clear idea now.


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