Chapter 25

Structure and Function Subjective Data—Health History

Questions Objective Data—The Physical Exam Abnormal Findings

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Usual bowel routine Change in bowel habits Rectal bleeding or blood in the stool Medications (laxatives, stool softeners, iron) Rectal conditions (pruritus, hemorrhoids, fissure,

fistula) Family history Self-care behaviors (diet of high-fiber foods, most

recent examinations)

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Preparation◦ Position

Equipment needed◦ Penlight◦ Lubricating jelly◦ Glove◦ Guaiac test container

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Inspection of the Perianal Area Skin Anal opening Sacrococcygeal area Valsalva maneuver

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Pilonidal cyst or sinus Anorectal fistula Fissure Hemorrhoids Rectal prolapse Pruritus ani

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Abscess Rectal polyp Fecal impaction Carcinoma

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Benign prostatic hypertrophy (BPH) Prostatitis Carcinoma Abscess Rectal polyp Fecal impaction Carcinoma

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