Gastrointestinal system

{Gastrointestinal system}

[+] yes, present, positive
[-] no, absent, negative
[~] equivocal
[\] not applicable, not performed
[?] unknown, unsure, unavailable
{ } annotation, comment

PRESENTING COMPLAINTS OR ISSUES
Reasons for visit:
[-] new problem/issue
[-] review/follow-up

Presenting symptoms:
[-] nausea
[-] vomiting
[-] anorexia
[-] fever, chills, sweats

[-] abdominal pain
  Pain location: 
  [-] RUQ, [-] epigastric, [-] LUQ
  [-] R Loin, [-] central, [-] L Loin
  [-] RLQ, [-] suprapubic, [-] LLQ
  
  Pain details:
    Onset: 
    Frequency: 
    Quality: 
    Radiation: 
    Severity /10: 
    Aggravating factors: 
    Relieving factors:

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

[-] weight loss
[-] weight gain
[-] mouth ulcers
[-] altered taste

History of presenting complaint:
  Onset: 
  Location: 
  Severity (/10): 
  Quality: 
  Timing: 
  Context: 
  Aggravated by: 
  Relieved by:

Management to date:
-

Diagnostic investigation results:
[+] 
[~] 
[-] 
[?]

PAST MEDICAL HISTORY
Relevant 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
[-] colitis
[-] cancer:

SOCIAL HISTORY
Social history:
[-] smoking
[-] alcohol use
[-] recent overseas travel

Occupational history: 
[-] farming
[-] sewer work
[-] work with animals/animal products

MEDICATIONS
Current or recent medications:
[-] corticosteroids
[-] aspirin/NSAIDs
[-] antibiotics
[-] H2 antagonists
[-] PPIs
[-] antacids

FAMILY HISTORY
Relevant family history:
[-] bowel cancer
[-] inflammatory bowel disease
[-] coeliac disease
[-] familial polyposis coli

PHYSICAL EXAMINATION
Relevant examination findings:
  Heart rate (bpm): 
  Blood pressure (mmHg): 
  Temperature (deg. C):

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

Other findings:
[-] jaundice
[-] clinical anaemia

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

PR examination: 
-

Investigation Results:

ASSESSMENT
Clinical summary:
[+] 
[~] 
[-]

Diagnosis/es:
1. 
2.

Differential diagnosis:
-

MANAGEMENT PLAN
Procedures performed:
-

Diagnostic investigations requested:
-

Referrals:
-

Information and advice given:
-

Medication:
-

FOLLOW-UP
Outstanding issues:
-

Next appointment:
-

[dqref.com 260131]

Gastrointestinal system

Related items