Wiki Physical exam of abdomen

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umas86

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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.
 
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
 
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.

Sometimes guarding is involuntary – the pain is bad enough that people can’t help tensing up. In its extreme – a rigid abdomen – it is tense even when the doctor isn’t pushing down on it. Then there is voluntary guarding, where the patient tenses up on purpose. Why someone would do this is mysterious to me.

Here are some possibilities:

The doctor’s hands have just come out of a bucket of ice (which I do on a regular basis).
The patient is trying to get the doctor to order a barium enema.
The patient wants to get the deductible met faster by having the doctor order a whole lot of tests.
The patient thinks “voluntary guarding” is a way of serving their country.
To uncover voluntary guarding, the doctor can put the stethoscope on the abdomen and push down. This tricks the patient, and they don’t tense up their abdomen – unless the doctor keeps the stethoscope in a bucket of ice like I do.

2. Nontender

The word tender can mean a lot of things:

To be kind and sympathetic
To be soft and easy to chew
To be inclined to roll when blown by the wind
To offer money as a payment
A railcar coupled to a steam locomotive to carry fuel and water
To be sensitive to pain.


Doctors use the last definition (although I sometimes use #3 when examining a boat). In short, if the patient says “Ow, that hurts” when I push on their abdomen, it is tender. Sometimes they just do involuntary guarding instead of saying “Ow, that hurts,” which makes it harder. And that, my friends, is what separates the good doctors from the ones with forged diplomas.

If a patient has a tender abdomen, it can mean they need surgery (appendix, gallbladder), need antibiotics (diverticulitis), or just need to poop. One of my attendings in residency referred to the last one as PID: “Poo in dere.” He told that joke all the time.

When pushing on the abdomen, I often tell a joke of my own. I tell patients that a trick doctors use is to push real hard on the abdomen so that it hurts. Then we can charge more. Pretty clever.

A sign of significant abdominal problems (possibly requiring surgery) is a condition called rebound. Rebound is pain that occurs when the examiner pushes in slowly and then lets go. If the patient has pain when the examiner stops pushing, they have rebound tenderness, which usually means there is serious inflammation in the abdominal cavity which could be life-threatening. If the patient asks the examiner for a date, they are probably just on the rebound.
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