Gastrointestinal System

#Gastrointestinal System

S: Subjective

Presenting Complaint: 
(-) nausea
(-) vomiting
(-) anorexia
(-) fever, chills, sweats

(-) abdominal pain
(-) chest/retrosternal pain
(-) heartburn
(-) dysphagia
(-) abdominal bloating
(-) flatulence
(-) diarrhoea
(-) constipation
(-) altered bowel habit
(-) haematemesis
(-) rectal pain
(-) PR bleeding
(-) melaena
(-) steatorrhoea
(-) jaundice
(-) dark urine

(-) weight loss
(-) weight gain
(-) mouth ulcers
(-) altered taste
(-) other ->

Symptom Development:
- Onset: 
- Variation: 
- Aggravating factors: 
- Relieving factors:

Past Medical History:
(-) GIT surgery
(-) GIT cancer
(-) inflammatory bowel disease
(-) peptic ulcer disease
(-) gluten enteropathy (coeliac disease)
(-) gluten intolerance
(-) FODMAP intolerance
(-) irritable bowel syndrome
(-) diverticular disease
(-) Other/s ->

Personal History:
(-) smoking
(-) alcohol use
(-) recent overseas travel

Occupational History: 
(-) farming
(-) sewer work
(-) work with animals/animal products

Treatment History:
(-) corticosteroids
(-) aspirin/NSAIDs
(-) antibiotics
(-) H2 antagonists
(-) PPIs
(-) antacids
(-) other ->

Family History: 
(-) bowel cancer
(-) inflammatory bowel disease
(-) coeliac disease
(-) familial polyposis coli
(-) other/s ->

O: Objective

Examination: 
- Heart rate (bpm): 
- Blood pressure (mmHg): 
- Temperature (deg. C):

- Height (m): 
- Weight (kg): 
- BMI (weight/height^2):

(-) jaundice
(-) clinical anaemia

Abdomen:
(-) distension
(-) tenderness
(-) rebound
(-) masses
(-) hepatomegaly
(-) splenomegaly
(-) inguinal hernia
(-) femoral hernia
(-) abnormal bowel sounds
(-) absent bowel sounds

PR Examination:

Investigation Results:

A: Assessment

Clinical Summary:

Diagnosis / DDx:

P: Plan

Investigations:

Treatment:

Referrals:

Patient Education / Home Care Advice:

Review:

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