A patient complains of abdominal pain. Her liver is larger than normal. How would you document this?

To document a patient's abdominal pain and liver enlargement, it is essential to be clear, concise, and systematic. Here’s a structured approach to documentation:

1. Patient Information: Include the patient's name, age, sex, and medical record number for identification.

2. Chief Complaint: State the primary issue — in this case, "The patient complains of abdominal pain."

3. History of Present Illness (HPI): Provide details about the abdominal pain, such as:

   • Location: Specify where the pain is located.
   • Quality: Describe the nature of the pain (sharp, dull, throbbing).
   • Duration: Note how long the patient has been experiencing the pain.
   • Radiation: Indicate if the pain radiates to other areas.
   • Severity: Rate the pain on a scale of 1 to 10.
   • Aggravating/Alleviating Factors: Mention what worsens or relieves the pain.

4. Physical Examination Findings:

   • Document the finding of liver enlargement: "Liver palpated 2 cm below the right costal margin on examination, consistent with hepatomegaly."
   • Include any additional examination results relevant to the abdominal assessment, such as tenderness, distension, or other organomegaly.

5. Assessment: Summarize your findings: "Patient presents with abdominal pain and signs of hepatomegaly, further evaluation required."

6. Plan: Outline the next steps, including any diagnostic tests (e.g., ultrasound, blood work) and potential referrals.

This structured documentation will ensure clarity and completeness in the medical record.