HISTORY:
weight loss for
Lost , from to
Changes in diet or eating habits:
Changes in physical activity:
, up to °, over
,
Other elements:
EXAM:
General appearance:
Vital signs: , BP , HR , RR , SpO2 %, Temp °
Neck:
Heart: ,
Lungs: ,
Breasts: -R: , -L:
Abdomen: , , ,
Pelvic: vulva , vagina , cervix , uterus , adnexa ,
Genital: , testicles , penis
Extremities: , , cap refill , pulses ,
Mental status: , , speech , mood , thought process , , judgment
ASSESSMENT:
DDx:
PLAN:
- Blood work: , , , , , , , , ,
- Upper GI endoscopy
- Colonoscopy
- Mammogram
- CT scan of thorax, abdomen, and pelvis
- PET scan
- High-calorie diet
- Nutritional supplements
- Referral to dietitian
- Referral to gastroenterologist
- Follow-up in
- Return if weight loss continues or if new symptoms develop