GI worksheet
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Florida College *
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Course
100
Subject
Medicine
Date
Dec 6, 2023
Type
docx
Pages
5
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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N380
GI/GU History and Exam
BP
Pulse
RR
Temp
Height
Weight
BMI
Physical Exam
Normal
Y
N
Comments
INSPECTION
Skin:
color, scars,
rashes or lesions
Contour:
shape
Symmetry
Umbilicus
Visible pulsations
Hernia
AUSCULTATION
Bowel sounds
Bruit
PERCUSSION
4 quadrants, note tones
Increased size of
liver/spleen
CVA tenderness
PALPATION
Light palpation
Deep palpation
Normal Exam Findings
Abdomen is flat, symmetric with no apparent masses, lesions, or
scars.
No pulsations noted on inspection.
Skin is appropriate for
N380
GI/GU History and Exam
ethnicity.
Hair distribution is WDL.
Bowel sounds present with no bruits.
Tympany predominated in all
4 quadrants.
Negative CVA tenderness.
Abdomen is soft to
palpation with no masses or tenderness.