(5) Constipation. Ask the patient about the frequency of bowel movements
Pain or cramps. Record the frequency and times that pain or cramps
c. Surgeries. Record information concerning operations. Include complications
and dates of operations involving the appendix, gallbladder, intestines, stomach, female
reproductive system, and genitourinary system.
d. Weight. Weight is an extremely important health issue. Record information
regarding the following:
Sudden increase or decrease in weight and accompanying reasons.
Obesity and accompanying complications.
Diets including types, dates, and times.
e. Trauma. Trauma and associated complications are also important and
should be noted. Use of drugs or alcohol (use or abuse) should be determined in detail.
EXAMINE THE PATIENT
Provide privacy for the patient. Examine the mouth and pharynx first, then the
abdomen, and, finally, the rectum. The examination should take place in a warm, well-
lighted room. The patient should be in the supine position, the abdomen exposed, legs
slightly flexed, and the arms to the side. Examination techniques must be performed in
this sequence: inspection, palpation, and percussion.
a. Mouth and Pharynx. The lips should be pink and smooth. Look for cold
sores, fever blisters, and chancre sores. The teeth should be white; gums should be
pink and moist. Look for inflammation, swelling, and bleeding. The tongue should look
velvety and pink. The palate should be firm and white. The pharynx should look pink
and smooth in nonsmokers and yellowish-red with small nodules in smokers. Inspect
(1) The quadrants. The abdomen is divided into four quadrants by
imaginary lines crossing as shown in figure 2-1. The quadrants are named as follows:
right upper quadrant (RUQ); left upper quadrant (LUQ); right lower quadrant (RLQ); and
left lower quadrant (LLQ).