Diarrhea HISTORY_LIST number of stools per hour per day loose or watery stool bloody stool pus in stool oily stool foul smelling stool fever malaise cramping abdominal pain tenesmus nausea vomiting ability to keep food or liquids down lightheadedness myalgia arthalgia headache upper respiratory infection back pain recent ingestion of spoiled food raw foods undercooked poultry raw milk raw or uncercooked seafood recent foreign travel laxative abuse long term antibiotic use recent contact with other persons with diarrhea rectal urgency stress related AIDS risk factors INFECTIOUS DISEASES AIDS or HIV CHRONIC DISEASE SYSTEMIC DISORDERS lactose intolerance diabetes inflammatory bowel dz. hyperthyroidism alcoholism SURGERY PREVIOUS HOSPITALIZATIONS abdominal intestinal PREVIOUS TESTS radiation TRAUMA OR INJURIES abdominal head trauma SOCIAL HISTORY smoking alcohol caffeine illicit drugs - cocaine ALLERGY medications foods seasonal FAMILY HISTORY coeliac dz. colon cancer diabetes immunosuppression MEDS_LAB_TESTS **** MEDS erythromycin clindyamycin magnesium containing antacids cholinergic agents quinidine antihypertensives colchicine association with caffeine chocolate candy milk products immunosuppression agents **** LAB Electrolytes BUN creatnine CBC calcium albumen Wright's stain stool C&S ova and parasites Clostridium difficile and toxins **** TESTS abdominal X-ray 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 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 in 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 psychiatric hospitalizations 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 Pulse Temp Heart rate GENERAL lethargic dehydrated SKIN skin turgor capillary refill jaundice erythema nodsum pyoderma gangrenosum HEENT oral ulcers (coeliac Dz. of IBD) cracked lips (riboflavin deficiency) dry mucus membranes glossitis (B12, folate deficiency) PHYSICAL_EVAL_2 ABDOMEN bowel sounds abdominal tenderness abdominal rebound hepatomegly distention pulsatile masses GU perianal ulcers rectal ulcers rectal tags fissures hemorrhoids sphincter tone rectal tenderness rectal masses blood on examining glove occult blood positive rectal pus EXTREMITIES back pain arthritis arthritis joint swelling (Ulcerative colitis) joint pain DIFF_DIAGNOSIS OSMOTIC DIARRHEA laxatives lactulose deficiency lactase deficiency (gastroenteritis or sprue) other disaccharidase deficiencies SECRETORY DIARRHEA bacterial infection AIDS associated disorders (mycobacterial) Zollinger-Ellison syndrome vasoactive intestinal peptide tumor carcinoid tumor medullary thyroid carcinoma colonic villus adenoma EXUDATIVE DIARRHEA bacterial infections Clostridium difficile viruses parasites Crohn's dz. ulcerative colitis diverticulitis chemotherapy intestinal ischemia DIARRHEA 2nd TO CHANGE IN INTESTINAL MOTILITY diabetic gastroparesis adrenal insufficiency hypothyroidism laxatives antibiotics cholinergics irritable bowel syndrome GI bleeding DIARRHEA 2nd TO DEC. SURFACE ABSORPTION bowel resection fistulas