Transcription
Hello, you are the duty doctor. You have been called to the admission department to conduct a physical examination of the patient's gastrointestinal tract. You need to perform the procedure and fill out the medical documentation. Please proceed.
Greet the patient, introduce yourself, and state your role.
Hello, I am a doctor. I will conduct a physical examination. Please have a seat. Please introduce yourself and state your age.
Have a seat. Please introduce yourself.
Ivanov Ivan Ivanovich. How old are you?
35 years old.
Inquire about the patient's well-being, inform them about the upcoming procedures, and obtain voluntary consent.
Ivan Ivanovich, how are you feeling?
Everything is fine, thank you.
Do you consent to the physical examination?
Yes, I consent.
Ask questions about complaints and other factors.
Ivan Ivanovich, when did you last eat?
I ate 4 hours ago.
When was your last urination?
Two hours ago.
Does your stomach hurt now?
It does not hurt.
When was your last bowel movement?
Ensure in advance that all necessary items are available: stethoscope, alcohol wipes, container for class B waste.
Prepare the patient by asking them to lie down on the couch.
Ivan Ivanovich, please lie down on the couch.
Begin the hygienic preparation of the skin and proceed.
Please expose your abdomen. We will assume the abdomen is exposed.
Begin the patient's examination.
I am examining the skin. The skin is of normal color.
I am examining the palms and fingers of the hands. We will assume the palms and fingers of the hands have been examined.
I am examining the oral cavity. We will assume the oral cavity has been examined.
Begin superficial palpation of the abdomen. Palpate the abdominal wall, starting from the left iliac region, right iliac region, left flank region, right flank region, left hypochondriac region, right hypochondriac region. Palpate the abdominal wall in the epigastric region, umbilical region, suprapubic region. Assess the condition of the aponeurosis. Palpate the linea alba along its entire length. Palpate the umbilical ring.
Please sit up. You can lie down without using your hands.
Assess for fluctuation.
Please place your hand on your abdomen.
Begin deep palpation of the abdomen.
Palpation of the sigmoid colon.
Palpation of the cecum.
Palpation of the ascending colon.
Palpation of the descending colon.
Determine the lower border of the stomach.
Place the head of the stethoscope in the epigastrium along the midline. Make tangential movements with your index finger from the base of the xiphoid process towards the navel.
We will assume the lower border of the stomach is two centimeters above the navel.
Palpation of the transverse colon.
Determine the lower border of the liver by percussion.
Palpation of the liver.
Take a deep breath. Exhale.
Palpation of the spleen.
Deep breath. Exhale.
Begin palpation and auscultation of the abdominal vessels.
Begin palpation of the abdominal aorta by placing your palms longitudinally at an equal distance on both sides of the midline of the abdomen.
The pulsation of the abdominal aorta is unremarkable.
Begin auscultation of the abdominal aorta.
Place the head of the stethoscope two centimeters above the navel along the linea alba.
Please hold your breath.
Hold your breath. Breathe.
Move the head of the stethoscope to the area along the outer edge of the rectus abdominis muscle on the left at the level of the navel.
Hold your breath. Breathe.
Move the head of the stethoscope along the outer edge of the rectus abdominis muscle on the right at the level of the navel.
Hold your breath. Breathe.
Auscultation of the abdominal aorta is unremarkable.
Complete the examination.
The examination is complete. You can get dressed. I will process the medical equipment and fill out the necessary documentation.