Gastrointestinal Symptoms
Age: years old
Gender:
HISTORY:
Presents with a - history of gastrointestinal symptoms
Symptoms include:
, episodes , ,
, episodes ,
, , ,
, over ,
, up to °, over
last menstrual period: ago
Worsening factors:
Alleviating factors: ,
Contributing factors:
no history of: , , , , ,
no use of: , , , , ,
no family history of:
EXAM:
General appearance: ,
Vital signs: , BP , HR , RR , SpO2 %, Temp °
Neck: , , , c-spine
Heart: , ,
Lungs: , ,
Abdomen: , , , , bowel sounds , ,
Anorectal: DRE , prostate , , , anus
Pelvic: external genitalia , vagina , cervix , uterus , adnexa ,
Genital: penis , testes and epididymis ,
Extremities: , , cap refill sec, pulses , ,
ASSESSMENT:
DDx: functional gastrointestinal symptoms, gastroenteritis, irritable bowel syndrome, inflammatory bowel disease, GERD, peptic ulcer disease, appendicitis, diverticulitis, colorectal cancer, food intolerance, lactose intolerance, celiac disease, pancreatic insufficiency, biliary tract disease, intestinal obstruction, constipatin, medication side effects, small intestinal bacterial overgrowth, ischemic colitis, radiation enteritis, mesenteric ischemia, intestinal parasites, bacterial gastroenteritis, traveler's diarrhea, food poisoning, functional dyspepsia, chronic mesenteric insufficiency, giardiasis, cryptosporidiosis, whipple's disease, tropical sprue, intestinal tuberculosis, intestinal lymphoma, gastric cancer
PLAN:
Investigations:
- Blood work: , , , , , ,
- Stools: , ,
- Abdominal X-ray
- Ultrasound of the abdomen
- Upper GI endoscopy
- Colonoscopy
Treatments:
- Dietary modifications: , ,
-
Further care:
- Referral to gastroenterologist
- Referral to dietitian
- Follow-up in
- Return if symptoms worsen or if new symptoms develop such as weight loss, blood in stools, or fever
HISTORY: EXAM: ASSESSMENT: PLAN: