Gastrointestinal Symptoms

HISTORY:

Gastrointestinal symptoms for ‍ ‍hoursdays

‍nausea

‍vomiting

‍hematemesis

‍bloating

‍diarrhea

‍constipation

‍changes in bowel habits

‍abdominal pain

‍heartburn

‍dysphagia

‍dyspepsia

‍loss of appetite

‍weight loss

‍fever

‍chills

‍jaundice

‍dizziness

Last menstrual period: ‍ ‍daysweeksmonths ago

Worsening factors: ‍none

Alleviating factors: ‍none, ‍effectiveineffective



EXAM:

General appearance: ‍well-appearing

Vital signs: ‍normal, BP ‍, HR ‍, RR ‍, SpO2 ‍ %, Temp ‍°

Neck: ‍normallymphadenopathy

Heart: ‍RRR, ‍normal S1 and S2

Lungs: ‍clearabnormal sounds, ‍retractions

Abdomen: ‍softsemi-softtense, ‍non-tender ‍, ‍non-distended, ‍

Pelvic: vulva ‍normal, vagina ‍normal, cervix ‍normal, uterus ‍normal, adnexa ‍normal, ‍no cervical motion tenderness

Genital: ‍normal, testicles ‍normal, penis ‍normal

Extremities: ‍edema, ‍warm, cap refill ‍< 3 sec> 3 sec, pulses ‍normal, ‍



ASSESSMENT:

‍Functional gastrointestinal symptoms ‍likelysuspectedpossible

DDx: ‍



PLAN:

- Blood work: ‍CBC, ‍CRP, ‍electrolytes, ‍creatinine, ‍glucose, ‍LFTs, ‍lipase

- Stools: ‍bacterial culture, ‍parasitic culture, ‍C. difficile toxin

- Abdominal X-ray

- Ultrasound of the abdomen

- Upper GI endoscopy

- Colonoscopy

- Dietary modifications: ‍avoid spicy foods, ‍increase fiber intake, ‍avoid trigger foods

- ‍GI medications

- Referral to gastroenterologist

- Referral to dietitian

- Follow-up in ‍ ‍weeksmonths

- Return if symptoms worsen or if new symptoms develop such as weight loss, blood in stools, or fever