How To Write A Case Report Patient M's Lower Abdomen

At 1915, I gave handoff report to Nurse C. At this time, Patient M’s vital signs remained stable: heart rate 71, Blood pressure 116/75, respirations 15, O2 saturation 97% on room air. As Nurse C and I assessed Patient M’s groin site, we noted an increasing amount of moderate light red drainage to Patient M’s dressing. Patient M complained of 7/10 pain to his right femoral site and right lower quadrant of his abdomen upon palpation. Patient M’s lower abdomen also felt firm.