GI worksheet

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Florida College *

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100

Subject

Medicine

Date

Dec 6, 2023

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docx

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Uploaded by PresidentPowerRaven21

N380 GI/GU History and Exam IDENTIFYING INFORMATION Patient Age Gender SUBJECTIVE Chief Complaint (CC): Why is patient here today? History of Present Illness (HPI): Past Medical History Yes No Comments PMH: HTN DM Heart disease Kidney stones UTI Gall stones Ulcers Anorexia Appendicitis Diverticulitis Irritable bowel syndrome Colon cancer Blood transfusions Hepatitis Abdominal surgery

N380 GI/GU History and Exam FH: Crohn’s disease Colitis Kidney disease DM HTN Heart disease Colon or stomach cancer Social History: Diet (24 hour recall) Smoking Alcohol Recreational drug use Exercise Work environment Living arrangement Recent travel Allergies: seasonal, environmental, food and medications Medications Immunizations Last Examination Last colonoscopy REVIEW OF SYSTEMS Yes No Comments (OLDCARTS) Pain

N380 GI/GU History and Exam Nausea/Vomiting Diarrhea Constipation Weight loss Weight gain Goal weight Change in appetite, taste, smell Food sensitivities Heartburn Gas/Bloating Difficulty swallowing Changes in urine color Urinary frequency or urgency Dysuria Nocturia Hematuria Jaundice Rectal bleeding Black stools OBJECTIVE: PHYSICAL EXAM Vital signs

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