iRubric: Abdominal Examination rubric

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Abdominal Examination

Rubric for the abdominal exam portion of a physical exam

Rubric Code: WXA23XW

By lesliemccoy

Ready to use

Public Rubric

Subject: Medical

Type: Assessment

Grade Levels: Graduate

Abdominal Exam
	Poor (N/A)	Fair (N/A)	Good (N/A)	Excellent (N/A)
Preparation	Poor 1. Hands not washed 2. Patient's knees not bent 3. Patient not examined from the right side.	Fair 1. Hands washed But none of the following: 2. Patient's knees bent -or- 3. Patient examined from the right side.	Good 1. Hands washed But only one of the following: 2. Patient's knees bent -or- 3. Patient examined from the right side.	Excellent 1. The examiner washed his/her hands 2. The patient's knees are bent -or- a bolster is placed under the knees 3. Examine the patient from the patient's right side
Visual Inspection	Poor Abdomen not inspected for: 1. Color, veins, scars 2. Contour & symmetry 3. Surface motion 4. Patient not asked to raise head to reveal hernia or split muscles	Fair Abdomen inspected for 2 of the following: 1. Color, veins, scars 2. Contour & symmetry 3. Surface motion 4. Ask patient to raise head to reveal hernia or split muscles	Good Abdomen inspected for 3 of the following: 1. Color, veins, scars 2. Contour & symmetry 3. Surface motion 4. Ask patient to raise head to reveal hernia or split muscles	Excellent Abdomen inspected for: 1. Color, veins, scars 2. Contour & symmetry 3. Surface motion 4. Ask patient to raise head to reveal hernia or split muscles
Auscultation	Poor The examiner did not: 1. Auscultated for bowel sounds 2. Auscultated for friction rubs over the liver and spleen 3. Auscultated for bruits in the correct position for the aorta, renal arteries, iliac arteries, and femoral arteries	Fair The examiner performed 1 of the following: 1. Auscultated for bowel sounds 2. Auscultated for friction rubs over the liver and spleen 3. Auscultated for bruits in the correct position for the aorta, renal arteries, iliac arteries, and femoral arteries	Good The examiner performed 2 of the following: 1. Auscultated for bowel sounds 2. Auscultated for friction rubs over the liver and spleen 3. Auscultated for bruits in the correct position for the aorta, renal arteries, iliac arteries, and femoral arteries	Excellent The examiner: 1. Auscultated for bowel sounds 2. Auscultated for friction rubs over the liver and spleen 3. Auscultated for bruits in the correct position for the aorta, renal arteries, iliac arteries, and femoral arteries
Percussion	Poor The examiner performed 1 or less of the following: 1. Percussed all four quadrants for tympany & dullness 2. Percussed upward along R mid-clavicular line to find lower border of liver. 3. Percussed downward along the R mid-clavicular line from 3rd ICS to find upper border of liver 4. Percussed lateral to the L mid-clavicular line to assess spleen enlargement	Fair The examiner performed 2 of the following: 1. Percussed all four quadrants for tympany & dullness 2. Percussed upward along R mid-clavicular line to find lower border of liver. 3. Percussed downward along the R mid-clavicular line from 3rd ICS to find upper border of liver 4. Percussed lateral to the L mid-clavicular line to assess spleen enlargement	Good The examiner performed 3 of the following: 1. Percussed all four quadrants for tympany & dullness 2. Percussed upward along R mid-clavicular line to find lower border of liver. 3. Percussed downward along the R mid-clavicular line from 3rd ICS to find upper border of liver 4. Percussed lateral to the L mid-clavicular line to assess spleen enlargement	Excellent The examiner: 1. Percussed all four quadrants for tympany & dullness 2. Percussed upward along R mid-clavicular line to find lower border of liver. 3. Percussed downward along the R mid-clavicular line from 3rd ICS to find upper border of liver 4. Percussed lateral to the L mid-clavicular line to assess spleen enlargement
Light Palpation	Poor The examiner did not: 1. lightly palpated the patient with a flat hand 2. palpated using a circular motion 3. Assessed the abdomen for muscular resistance, tenderness and masses	Fair The examiner performed 1 of the following: 1. lightly palpated the patient with a flat hand 2. palpated using a circular motion 3. Assessed the abdomen for muscular resistance, tenderness and masses	Good The examiner performed 2 of the following: 1. lightly palpated the patient with a flat hand 2. palpated using a circular motion 3. Assessed the abdomen for muscular resistance, tenderness and masses	Excellent The examiner: 1. lightly palpated the patient with a flat hand 2. palpated using a circular motion 3. Assessed the abdomen for muscular resistance, tenderness and masses
Deep Palpation	Poor The examiner performed 2 or less of the following: 1. Used a bimanual technique 2. palpated the umbilical ring 3. palpated the lower border of the liver 4. instructed the patient to inhale, watching for flinching or pain (murphy's sign) 5. Palpated the splenic region with one hand in abdomen and other hand on the costovertebral angle 6. Palpated the aorta	Fair The examiner performed 3 of the following: 1. Used a bimanual technique 2. palpated the umbilical ring 3. palpated the lower border of the liver 4. instructed the patient to inhale, watching for flinching or pain (murphy's sign) 5. Palpated the splenic region with one hand in abdomen and other hand on the costovertebral angle 6. Palpated the aorta	Good The examiner performed 4 of the following: 1. Used a bimanual technique 2. palpated the umbilical ring 3. palpated the lower border of the liver 4. instructed the patient to inhale, watching for flinching or pain (murphy's sign) 5. Palpated the splenic region with one hand in abdomen and other hand on the costovertebral angle 6. Palpated the aorta	Excellent The examiner: 1. Used a bimanual technique 2. palpated the umbilical ring 3. palpated the lower border of the liver 4. instructed the patient to inhale, watching for flinching or pain (murphy's sign) 5. Palpated the splenic region with one hand in abdomen and other hand on the costovertebral angle 6. Palpated the aorta
Kidney Palpation & Percussion	Poor The examiner did none of the following: 1. Palpated the area of kidney with one hand in costal margin and other hand at flank 2. Asked patient to take a deep breath 3. Percussed the costovertebral angle with hand over hand technique	Fair The examiner performed 1 of the following: 1. Palpated the area of kidney with one hand in costal margin and other hand at flank 2. Asked patient to take a deep breath 3. Percussed the costovertebral angle with hand over hand technique	Good The examiner performed 2 of the following: 1. Palpated the area of kidney with one hand in costal margin and other hand at flank 2. Asked patient to take a deep breath 3. Percussed the costovertebral angle with hand over hand technique	Excellent The examiner: 1. Palpated the area of kidney with one hand in costal margin and other hand at flank 2. Asked patient to take a deep breath 3. Percussed the costovertebral angle with hand over hand technique
Rebound tenderness	Poor The examiner did none of the following: 1. Correctly locates McBurney's point 2. Palpates deeply at McBurney's point 3. Quickly removes fingers 4. Watches for flinching	Fair The examiner performed 2 of the following: 1. Correctly locates McBurney's point 2. Palpates deeply at McBurney's point 3. Quickly removes fingers 4. Watches for flinching	Good The examiner performed 3 of the following: 1. Correctly locates McBurney's point 2. Palpates deeply at McBurney's point 3. Quickly removes fingers 4. Watches for flinching	Excellent The examiner: 1. Correctly locates McBurney's point 2. Palpates deeply at McBurney's point 3. Quickly removes fingers 4. Watches for flinching

Keywords:

abdominal exam, physical exam

Subjects:

Medical

Types:

Assessment

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