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