Hepatobiliary System

#Hepatobiliary System

S: Subjective

Presenting Complaint:
(-) abdominal pain, location -> 
(-) abdominal bloating

(-) jaundice
(-) dark urine
(-) steatorrhoea
(-) pale stools
(-) pruritis

(-) fever
(-) nausea
(-) vomiting

(-) flatulence
(-) diarrhoea
(-) constipation
(-) altered bowel habit
(-) haematemesis
(-) PR bleeding
(-) melaena

(-) anorexia
(-) weight loss
(-) weight gain
(-) other/s ->

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

Past Medical History: 
(-) hepatitis, type -> 
(-) jaundice
(-) blood transfusions
(-) intravenous drug use
(-) tattoos
(-) STIs, details ->

Immunisations: 
(-) hepatitis B

Treatment History: 
(-) abdominal surgery
(-) oral contraceptive use

Family History: 
(-) haemochromatosis
(-) genetic liver diaesse (eg Wilson disease)

Social History: 
(-) alcohol use
(-) recent contact with jaundiced person

Occupational History: 
(-) organic solvent exposure
(-) work with animals, details ->

O: Objective

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

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

(-) jaundice 
(-) caput medusae
(-) hepatomegaly
(-) splenomegaly
(-) ascites
(-) abdominal tenderness, location/s ->

Investigation Results:

A: Assessment

Clinical Summary:

Diagnosis / DDx:

P: Plan

Investigations:

Treatment:

Referrals:

Patient Education / Home Care Advice:

Review:

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