Nausea & Vomiting HISTORY_LIST character & contents of emesis vertigo tinnitus abdominal pain effect of vomiting on pain early satiety fever headache weakness chest pain melena clay colored stool dark urine jaundice myalgia recent change in medications ingestion: spoiled/contaminated food pregnant Last menstrual period heavy metal poisoning INFECTIOUS DISEASES intestinal virus CHRONIC DISEASE OR SYSTEMIC DISORDERS diabetes cardiac dz. gastric or duodenal ulcer liver dz. PREVIOUS TESTS X-rays of abdomen upper GI series SOCIAL HISTORY smoking alcohol caffeine illicit drugs - cocaine ALLERGY medications foods seasonal FAMILY HISTORY diabetes cardiac dz. gastric or duodenal ulcers MEDS_LAB_TESTS **** MEDS Colchicine Digoxin Aminophylline chemotherapy alcohol anticholinergics morphine Demerol ergot oral contraceptives estrogen antiarrhythmics **** LAB Vomitus occult blood Electrolytes BUN creatnine CBC LFT pregnancy test **** TESTS ECG CXR Upper GI series Endoscopy 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 Postural BP Pulse Temp Heart rate GENERAL nauseated lethargic SKIN temperature pallor jaundice spider angioma HEENT nystagmus papilledema absent venous pulsations ketone odor on breath PHYSICAL_EVAL_2 NECK JVD ABDOMEN scars bowel sounds bruits tenderness rebound rigidity distention splenomegaly hepatomegaly ascites GU occult blood EXTREMITIES edema DIFF_DIAGNOSIS GI tract infection: Bacterial, viral, or parasitic Gastroenteritis systemic infections medication appendicitis cholecystitis hepatitis intestinal obstruction peptic ulcer or bleeding gastroparesis MI elev. intracranial pressure labyrinthitis Meniere's dz. heart failure diabetic ketoacidosis hypothyroidism adrenal insufficiency pregnancy uremia toxemia bulimia psychogenic