Lower GI Bleed & Melenoma

HISTORY_LIST
duration
quantity of blood
color of blood (bright red)
vomiting prior to blood
abdominal pain
fever
constipation
diarrhea
ingestion of alcohol, aspirin,
   NSAIDS, steroids,iron,
   potassium supplements,
   anticoagulants, quinidine,
   tetracycline, dipyridamole
nose bleed
vomiting
nausea
mucus from rectum
pus from rectum
tenesmus
anorectal pain
syncope
light headedness
nausea
diaphoresis
black stool: Pepto Bismol/iron
false negative hemoccult: 
   recent ingestion: Vit C
false positive hemoccult:
   recent ingestion: red meat,
     broccoli, radishes,
     cauliflower, beets,
     cantaloupe, turnips
CHRONIC DISEASE 
SYSTEMIC DISORDERS
ulcers
esophagitis
bleeding disorders
liver dz.
renal dz.
coronary dz.
aortic stenosis
diverticulosis
hemorrhoids
colitis
colon polyps
cirrhosis
alcoholism
SURGERY
PREVIOUS HOSPITALIZATIONS
abdominal surgery
aortic surgery
PREVIOUS TESTS
recent hematocrit
X-rays
endoscopy
colonoscopy
TRAUMA OR INJURIES
abdominal trauma
chest trauma
SOCIAL HISTORY
smoking
alcohol
caffeine
illicit drugs - cocaine
ALLERGY
medications
foods
seasonal
FAMILY HISTORY
blood disorders
liver dz.
alcoholism

MEDS_LAB_TESTS
**** MEDS
aspirin
NSAIDS
steroids
ampicillin
anticoagulants
**** LABS
Electrolytes
BUN
   (elev. BUN: upper GI bleed)
creatnine
CBC
LFT
PT/PTT
bleeding time
**** TESTS
Upright abdominal x-ray
EGD
endoscopy
colonoscopy
abdominal CT or MRI

REVIEW_OF_SYSTEMS_1
GENERAL
weight changes
appetite changes
anorexia
difficulty sleeping
fever
chills
polyphagia
hypophagia
changes in thirst
sleeping habit change
bowel habit change
fatigue
hypertension
previous physical exams
SKIN
pigmentation changes
texture changes
lesions
eruptions
pruritis
easy bruising
easy bleeding
unusual hair loss
changes in hair distribution
skin masses
finger/toe nail change
rashes
hives
striae
skin atrophy
uremic frost
hirsutism
plethora
neurofibromatosis lesion
HEENT
head trauma
skull fractures
head masses
hearing loss
vertigo
chronic ear infection
ear discharge
ear pain
hearing aid use
loss of vision
recent change in vision
photophobia
diplopia (double vision)
glaucoma
exudates
dry eyes
eye pain
cataracts
eye surgery
itchy eyes
excessive tearing
corrective lenses
nose bleeds
chronic sinusitis
nasal fractures
nasal drainage
polyps
changes in sense of smell
edentulous (without teeth)
partial plate
full plate
recent dental work
oral lesions
tonsillitis
strep throat
tongue problems
voice changes
chronic hoarseness
chronic halitosis
NECK
neck masses
enlarged thyroid gland
brachial cleft cysts
neck injury

REVIEW_OF_SYSTEMS_2
CHEST
chronic coughing
sputum production
hemoptysis
wheezing
pneumonia
bronchitis
TB
TB exposure
SOB (altered by position?)
edema
chest pains
pacemaker
HEART
MI
coronary artery disease
heart murmur
heart valve disease
left ventricular hypertrophy
mistral valve stenosis
pericarditis
palpitations
DOE
paroxysmal nocturnal dyspnea
orthopnea
edema
hypertension
rheumatic fever
cardiomyopathy
ectopic heart beats
arrhythmia
exercise intolerance
claudication
heart medications
ABDOMEN
abdominal pain
nausea
vomiting
diarrhea
constipation
hematochezia
hematemesis
hemorrhoids
GI x-rays
GI scopings
rectal bleeding
ulcers
bowel polyps
bowel incontinence
gall bladder disease
gall stones
hepatitis
cirrhosis
hepatomegaly
splenomegaly
GU
renal insufficiency
renal failure
dialysis
kidney stones
kidney disease
kidney cyst
flank pain
hematuria
pyuria
dysuria
chronic cystitis
nocturia
anuria
hesitancy
enuresis
change in urine color
prostatitis
epididymitis
scrotal problems
TURP
pain on intercourse
genital lesions
genital discharge

REVIEW_OF_SYSTEMS_3
OB/GYN
metorrhagia
menorrhagia
irregular menses
problems in pregnancy
use of contraception
breast masses
nipple discharge
breast skin changes
changes in axillary nodes
monthly breast exam
breast feeding children
EXTREMITIES
difficulty with gait
weakness
joint swelling
joint stiffness
muscle pain
muscle swelling
muscle injuries
sagittal plan scoliosis
coronal plane scoliosis
fractured bones
SLE
osteoarthritis
rheumatoid arthritis
fibromyalgia
NEURO
seizures
head injury
LOC
loss of coordination
difficulty in balance
sciatica
difficulty: fine motor skills
difficulty speaking
CVA (stroke)
weakness in arms
weakness in legs
tingling in legs and feet
tingling in arms
PSYCHIATRIC
depression
bipolar disorder
suicide attempts
hospitalization
   for psychiatric problems
personality disorders
ENDOCRINE
goiter
exophthalmos
dry skin
dry hair
intolerance to heat
intolerance to cold
changes in growth
sterility
impotence
decreased libido
LYMPHATIC AND HEMATOLOGICAL
lymphadenopathy
transfusion
anemia




PHYSICAL_EVAL_1
VITALS
BP
Supine Pulse
Upright Pulse
Temp
Heart rate
GENERAL
pallor
diaphoresis
agitation
confusion
SKIN
delayed capillary refill
pallor
cold, clammy extremities
petechiae
ecchymosis
umbilical venous collaterals 
   (caput medusae)
jaundice
spider angiomas
rashes
purpurs
HEENT
atherosclerotic retinal dz.
   (ischemic colitis)
retinal "silver wire" arteries
parotid gland hypertrophy
buccal mucosa discolorations
   or pigmentation
   (Henoch-Schonlein purpura or
   Peutz-Jeghers polposis syndrome)
scleral pallor
oral telangiectasia
NECK
flat neck veins

PHYSICAL_EVAL_2
CHEST
gynecomastia in males
breast masses
HEART
systolic ejection murmur
   (aortic stenoisi)
atrial fibrillation
   (mesenteric emboli)
ABDOMEN
scars
bowel sounds
tenderness
rebound
masses
hernias
splenomegaly
increased liver span
hepatomegaly
liver nodules
ascites
bruits
dilated abdominal veins
pulsatile masses
GU
gross blood
occult blood (guaic positive)
rectal masses
hemorrhoids
anal fissures or tears
rectal polyps
rectal ulcers
testicular atrophy
EXTREMITIES
edema
bone pain
NEURO
mental status
confusion
memory
asterixis




DIFF_DIAGNOSIS
hemorrhoids
fissures
diverticulosis
rectal trauma
protitis
Inflammatory Bowel Dz.
   (Crohn's Dz.
    or ulcerative colitis)
GI infection
ischemic colitis
polyps
carcinoma
swallowed blood
   (nose bleed or oral lesion)
vascular ectasias
duodenitis
coagulopathy
vasculitis
intussusception
ulceraions
autoimmune dz.
Meckel's diverticulitis
STIGMATA OF LIVER DISEASE
umbilical venous collaterals
   (caput medusae)
jaundice
spider angiomas
parotid gland hypertrophy
gynecomastia


