Patient Information
Name:
Age/Sex:
Address:
Educational status:
Occupation:
Chief Complaints
Chief Complaints in chronological order with duration.
History of Presenting Illness
1. Abdominal Pain
Onset: Sudden / Gradual
Duration: ______________________
Progression: Progressive / Non-progressive
Site: RUQ / LUQ / RLQ / LLQ(Quadrants) / Diffuse
Character: Dull aching / Colicky / Burning / Cramping / Stabbing / Other: _____
Severity: ___________________
Radiation: None / Back / Right Shoulder / Groin / Other: __________
Aggravated By: Meals / Fatty food / Alcohol / Movement / Coughing / Fasting / Others _________
Relieved By: Food / Antacids / Vomiting / Defecation / Analgesics / Leaning forward / Others __________________
Associated With: Nausea / Vomiting / Fever / Jaundice / Abdominal Distension / Constipation / Diarrhoea / Weight Loss
2. Vomiting
Duration: ___________________
Episodes/day: ________________
Projectile / Non-projectile
Relation to meals: Before meals / After meals / No relation
Contents: Undigested food / Bilious / Fresh blood(Red or Coffee-ground coloured) / Feculent
Associated nausea: Present / Absent
Pain relieved after vomiting: Yes / No
3. Dysphagia & Odynophagia
Difficulty swallowing: Present / Absent
For: Solids / Liquids / Both
More for solids/liquids
Nature: Progressive / Intermittent
Associated: Painful swallowing / Regurgitation / Aspiration / Weight loss
4. Heartburn & Acid Regurgitation
• Retrosternal burning
• Sour regurgitation
Aggravated by: Spicy food / Heavy meals / Bending / Lying down
Relieved by: Antacids / PPIs
5. Appetite & Weight Loss
Appetite: Normal / Reduced / Increased
Early satiety: Present / Absent
Weight loss: ________ kg in ______ months
6. Altered Bowel Habits
Constipation: Present / Absent
Diarrhoea: Present / Absent
Alternating constipation & diarrhoea: Present / Absent
If diarrhoea: Acute / Chronic / Watery / Bloody / Mucoid
Associated with Urgency / Tenesmus
If constipation
Frequency __________________
Consistency ________________
Straining: Yes / No
Hard stools: Yes / No
7. Stool Characteristics
Normal / Hard / Loose
Colour: Black (Melena) / Fresh blood
Mucus
Pale / Clay coloured
Floating greasy stools
8. Jaundice
Yellow discoloration:Present / Absent
Dark urine: Yes / No
Associated: Itching / Pale stools / Fever / Abdominal pain / Bleeding manifestations
Risk factors: Previous jaundice / Blood transfusion / IV drug abuse / Tattooing / Unsafe sexual exposure / Alcohol intake
9. Abdominal Distension
Duration __________________
Onset: Sudden / Gradual
Progression: Progressive / Non-progressive
Distribution: Generalized / Localized
Associated: Pain / Vomiting / Constipation / Pedal edema / Breathlessness
10. GI Bleeding
• Hematemesis
• Melena
• Hematochezia
• Bleeding per rectum
Colour:
Quantity:
Frequency:
Associated dizziness/syncope: Present / Absent
Constitutional Symptoms
• Fever
• Weight loss
• Loss of appetite
• Fatigue
• Malaise
• Pruritus
Past History
History of
• Peptic ulcer disease
• GERD
• Hepatitis
• Chronic liver disease
• Gallstones
• Pancreatitis
• IBD
• Tuberculosis
• Diabetes
• Hypertension
• Previous abdominal surgery
• Blood transfusion
• Previous hospitalization
Drug History
History of
• NSAIDs
• Steroids
• Anticoagulants
• PPIs
• ATT
• Herbal medicines
• Indigenous medicines
Drug allergy __________________
Personal History
• Appetite: Normal / Reduced
• Diet: Vegetarian / Mixed
• Sleep: Adequate / Disturbed
• Bowel habits __________________
• Bladder habits ________________
Addiction History
Alcohol: No / Yes
-Type ______________________
-Quantity ___________________
-Duration ___________________
Smoking: No / Yes
-Pack years ________________
Occupational & Environmental History
• Contaminated food/water
• Recent travel
• Occupational toxin exposure
• Poor sanitation
Family History
History of
• DM, HTN, Tuberculosis
• Colorectal carcinoma
• Inflammatory bowel disease
• Liver disease
• Gallstones
• GI malignancy
Once history taking is complete, proceed to Abdominal Examination.
Mr./Ms. ______, a __-year-old Male/Female, resident of ______ and working as a ______, presented with complaints of __________ for the past _____ days/months/years.
The patient was apparently asymptomatic until _____ days ago when he/she developed abdominal pain, which was sudden/gradual in onset and gradually progressive/non-progressive in nature. The pain was localized to the Right upper quadrant / Right lower quadrant / Left upper quadrant / Left lower quadrant of abdomen or diffuse. It was dull aching/colicky/burning/cramping/stabbing in character, radiating to the back/right shoulder/groin or non-radiating.
The pain was aggravated by meals, fatty food, alcohol, movement, coughing, or fasting and relieved by food, antacids, vomiting, bowel evacuation, analgesics, or leaning forward. The pain was associated with nausea, vomiting, fever, abdominal distension, constipation, diarrhoea, jaundice, or weight loss.
- Burning epigastric pain relieved by food → Duodenal ulcer
- Burning epigastric pain aggravated by meals → Gastric ulcer
- Right hypochondrial pain after fatty meals → Cholelithiasis / Acute cholecystitis
- Severe epigastric pain radiating to back → Acute pancreatitis
- Colicky abdominal pain with vomiting and distension → Intestinal obstruction
- Migratory pain from umbilicus to right iliac fossa → Acute appendicitis
The patient developed vomiting since _____. It was ___ episodes/day, projectile/non-projectile, occurring before/after meals / no association with food intake. The vomitus contained undigested food/bile/blood (fresh or coffee-ground)/feculent material. Vomiting was preceded/not preceded by nausea. Vomiting was associated with abdominal pain and was/was not relieved after vomiting.
- Projectile vomiting → Gastric outlet obstruction, raised ICP
- Bilious vomiting → Small bowel obstruction
- Coffee-ground vomiting → Upper GI bleed
- Feculent vomiting → Distal intestinal obstruction
The patient did/did not complain of difficulty in swallowing since ___ days. If present, dysphagia was for solids/liquids/both (if both, mention more for solid/liquid), progressive/intermittent and associated with painful swallowing (odynophagia), regurgitation, aspiration, or weight loss.
- Progressive dysphagia (solids → liquids) → Esophageal carcinoma
- Intermittent dysphagia → Esophageal spasm
- Painful swallowing → Esophagitis
The patient complained/did not complain of retrosternal burning sensation and sour regurgitation since ___ days. Symptoms were aggravated by spicy food, heavy meals, bending forward, or lying down and relieved by antacids or PPIs.
- Gastroesophageal reflux disease (GERD)
- Hiatus hernia
- Peptic ulcer disease
The patient's appetite was normal/reduced/increased with or without early satiety. Weight loss of approximately _____ kg over _____ months was present/absent.
- Loss of appetite with weight loss → GI malignancy, chronic liver disease, tuberculosis
- Early satiety → Gastric carcinoma, massive splenomegaly, ascites
The patient complained/did not complain of constipation/diarrhoea/alternating constipation and diarrhoea. If diarrhoea was present, it was acute/chronic, watery/bloody/mucoid, associated with urgency or tenesmus. If constipation was present, stool frequency, consistency, straining, and passage of hard stools were noted.
- Bloody diarrhoea → Ulcerative colitis, dysentery
- Chronic diarrhoea with weight loss → Malabsorption, IBD
- Alternating constipation and diarrhoea → Colorectal carcinoma, IBS
The stools were normal/hard/loose, black (melena), pale/clay coloured, blood stained, or mucus mixed.
- Melena → Upper GI bleeding
- Fresh blood per rectum → Hemorrhoids, fissure, colorectal carcinoma
- Clay-coloured stools → Obstructive jaundice
- Floating greasy stools → Steatorrhoea
The patient developed/did not develop yellowish discoloration of eyes and urine since ____ days. It was associated with itching, pale stools, fever, abdominal pain, or bleeding manifestations. History of previous jaundice, blood transfusion, intravenous drug abuse, tattooing, unsafe sexual exposure, or alcohol consumption was elicited.
- Painful jaundice with fever → Acute cholangitis
- Painless progressive jaundice → Carcinoma head of pancreas
- Jaundice with ascites → Chronic liver disease
The patient developed abdominal distension since _____. It was gradual/sudden in onset, progressive/non-progressive, generalized/localized and associated with abdominal pain, constipation, vomiting, pedal edema, or breathlessness.
- Progressive abdominal distension → Ascites
- Distension with colicky pain and vomiting → Intestinal obstruction
- Massive distension with pedal edema → Chronic liver disease
The patient did/did not complain of hematemesis, melena, hematochezia, or bleeding per rectum since ____ days. If present, the quantity, colour, frequency, and associated dizziness or syncope were noted.
- Peptic ulcer disease
- Esophageal varices
- Colorectal carcinoma
- Hemorrhoids
- Anal fissure
History/ No history of loss of appetite, weight loss, fatigue, malaise, fever, and pruritus.
- Weight loss with anorexia → GI malignancy
- Pruritus with jaundice → Obstructive jaundice
- Fever with abdominal pain → Liver abscess, cholecystitis
Past History: History/ No History of peptic ulcer disease, GERD, hepatitis, chronic liver disease, pancreatitis, gallstones, inflammatory bowel disease, tuberculosis, diabetes, hypertension, abdominal surgeries, blood transfusions, or previous hospitalizations — present/absent.
Drug History: Patient was/not on NSAIDs, steroids, anticoagulants, PPIs, ATT, indigenous medications, or herbal drugs. No history of any drug allergy.
Personal History:His/ her Appetite is normal/reduced. He / She is Vegetarian/ consumes mixed diet. Sleep is adequate/disturbed. Bowel and bladder habits are normal/abnormal. History of Alcohol intake: present/absent — type, quantity, duration. History of Smoking: present/absent, pack years ______.
Occupational/Environmental: History of contaminated food/water, travel, occupational toxin exposure, or poor sanitation — present/absent.
Family History: History / No history of of colorectal carcinoma, inflammatory bowel disease, liver disease, gallstones, or GI malignancy in any first degree or second degree relatives.
Mr./Ms. ______, a __-year-old individual, presented with mild abdominal discomfort for ___ days with no history of vomiting, jaundice, altered bowel habits, GI bleeding, weight loss, alcohol abuse, significant past illness, or family history, suggestive of uncomplicated acute gastritis/dyspepsia.
