HISTORY:
Gastrointestinal symptoms for
Last menstrual period: ago
Worsening factors:
Alleviating factors: ,
Other elements:
EXAM:
General appearance:
Vital signs: , BP , HR , RR , SpO2 %, Temp °
Neck:
Heart: ,
Lungs: ,
Abdomen: , , ,
Pelvic: vulva , vagina , cervix , uterus , adnexa ,
Genital: , testicles , penis
Extremities: , , cap refill , pulses ,
ASSESSMENT:
DDx:
PLAN:
- Blood work: , , , , , ,
- Stools: , ,
- Abdominal X-ray
- Ultrasound of the abdomen
- Upper GI endoscopy
- Colonoscopy
- Dietary modifications: , ,
-
- 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