What is the recommended approach for charting right cerebral vascular accident (CVA) tenderness?

Documenting Right CVA Tenderness in Medical Charts

Right CVA tenderness should be documented as "right costovertebral angle tenderness" rather than "right cerebrovascular accident tenderness" to avoid confusion, as CVA is an abbreviation with multiple meanings in medical contexts.

Proper Documentation of CVA Tenderness

• In medical charting, CVA refers to "costovertebral angle" when discussing physical examination findings of the flank/kidney region, not "cerebrovascular accident" 1
• Document the specific location as "right CVA tenderness" or more explicitly as "right costovertebral angle tenderness" to avoid any confusion with cerebrovascular disease terminology 1
• Include details about the examination technique used (percussion or palpation) and the severity of tenderness (mild, moderate, severe) 1

Examination Technique for CVA Tenderness

• The proper technique involves having the patient sit or stand while the examiner places one hand flat over the costovertebral angle (where the last rib meets the spine) and then strikes that hand with the ulnar edge of the other hand 1
• Alternatively, direct palpation of the costovertebral angle can be performed and documented 1
• Document the patient's response to percussion (pain, wincing, guarding) 1

Clinical Significance of CVA Tenderness

• Right CVA tenderness is commonly associated with right kidney inflammation, infection, or obstruction 1
• Document associated symptoms that may help with diagnosis (fever, dysuria, hematuria, flank pain) 1
• Note any radiation of pain, which may indicate renal colic from nephrolithiasis 1

Avoiding Terminology Confusion

• The abbreviation "CVA" in medical contexts can refer to either "costovertebral angle" or "cerebrovascular accident" 1
• Cerebrovascular accident (stroke) is a completely different clinical entity defined as loss of neurological function caused by an ischemic or hemorrhagic event affecting the brain 1
• To prevent misinterpretation, consider spelling out "costovertebral angle tenderness" in full rather than using the abbreviation "CVA" 1

Documentation Example

• Example charting: "Patient exhibits moderate right costovertebral angle tenderness on percussion. No left CVA tenderness. Associated with fever of 101.2°F and dysuria." 1
• Include relevant negatives: "No abdominal guarding, no suprapubic tenderness" 1
• Document any diagnostic considerations based on the finding: "Concerning for possible pyelonephritis" 1

Common Pitfalls in Documentation

• Failing to specify right versus left CVA tenderness 1
• Using the abbreviation "CVA" without context, which could be misinterpreted as referring to a stroke 1
• Not documenting the severity of tenderness, which is important for tracking clinical improvement or deterioration 1
• Omitting the examination technique used (percussion vs. palpation) 1