Scribd Logo
Upload

Welcome to Scribd!

  • 59 views

    History Made Easy Notes

    Uploaded by

    Tahir Ali
    This document provides guidance on evaluating a patient presenting with weight loss. It outlines key areas to assess including the nature and duration of weight loss, nutritional status, psychological factors, past medical history including medications, abdominal symptoms, bowel habit changes, and relevant social history. The goal is to identify any alarming symptoms that may indicate an underlying medical condition and determine if weight loss is intentional or related to an underlying problem requiring treatment.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd

    History Made Easy Notes

    Uploaded by

    Tahir Ali
    59 views3 pages
    This document provides guidance on evaluating a patient presenting with weight loss. It outlines key areas to assess including the nature and duration of weight loss, nutritional status, psychological factors, past medical history including medications, abdominal symptoms, bowel habit changes, and relevant social history. The goal is to identify any alarming symptoms that may indicate an underlying medical condition and determine if weight loss is intentional or related to an underlying problem requiring treatment.

    Original Title

    HISTORY MADE EASY NOTES.docx

    Copyright

    © © All Rights Reserved

    Available Formats

    DOCX, PDF, TXT or read online from Scribd

    Did you find this document useful?

    Is this content inappropriate?

    This document provides guidance on evaluating a patient presenting with weight loss. It outlines key areas to assess including the nature and duration of weight loss, nutritional status, psychological factors, past medical history including medications, abdominal symptoms, bowel habit changes, and relevant social history. The goal is to identify any alarming symptoms that may indicate an underlying medical condition and determine if weight loss is intentional or related to an underlying problem requiring treatment.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    59 views3 pages

    History Made Easy Notes

    Uploaded by

    Tahir Ali
    This document provides guidance on evaluating a patient presenting with weight loss. It outlines key areas to assess including the nature and duration of weight loss, nutritional status, psychological factors, past medical history including medications, abdominal symptoms, bowel habit changes, and relevant social history. The goal is to identify any alarming symptoms that may indicate an underlying medical condition and determine if weight loss is intentional or related to an underlying problem requiring treatment.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    You are on page 1of 3

    WEIGHT LOSS

    ANY OTHER CONCERN: ANY THING THAT IS WORRYING YOU MIGHT BE CAUSING IT

    NATURE OF WT LOSS: AMOUNT, DURATION, INTENTIONAL, APPETITE, CONCORDANCE WITH CHNGE IN


    DIET+PHYSICAL ACTIVTY OR LIFESTYLE

    ALARM SYMPTOMS: EARLY SATIETY, DYSPHAGIA, TUMMY PAIN, CHANGE IN BOWL HABIT
    (DIARRHEACONSTIPATION,PALE STOOLS),BLOOD IN STOOL,COUGH WITH HEMOPTYSIS ,BONY
    PAINS,ENDOCRINE (THYROID+ADDISON )

    NUTRITIONAL STATUS: NO OF MEALS+SNACK/24 HOURS, DIET CONTAIN MEAT+DAIRY PRODCT, WHO COOK
    ,WETHER FINISH PORTION OR NOT,ANY NUTRITIONAL +VITAMIN SUPPLMNT,ANY DIETRY CONSULTXX

    PSYCOLOGICAL ISSUES: HOW HAS YOUR MOOD BEEN OVER RECENT WEEKS, ANY FLUCTUTATION IN WT

    PAST MEDICAL: CHRONIC MED CONDITIONS: CCF,CRF,T2DM,COPD,PUD,PANC COND,CROHN,PERIPHERAL


    VAS DISEASE
    PAST SRGICAL +FAMILY HX: GUT SURGERIES + FAMILY HX OF CANCERS

    MEDICATIONS: EFFECT ON APPETITE (SSRI+LEVADOPA+METFORMIN+DIGOXIN, THEOPHYLLIN), EFFECT ON


    GIT =DRY MOUTH (ANT CHOLINERGICS,DIURETICS),DYSPHAGIA ( BISPHOPHONATES,NSIADS),NAUSEA
    (DIGOXIN ,METFORMIN+IRON ),PANCREATITIS (AZTHIPRINE,HIV DRUGS,THAIZIDE ,FLAGYL),RECREATIONAL
    DRUGS ( COAIN+AMPHETAMINES )

    SOCIAL ISSUES: DRINK+ALCOHAL +TRAVEL (HIV+GAIRDIA+TB)

    ABDOMINAL PAIN .DYSPEPSIA

    LOCATION : EPIG.APUD+PANCREATIC/RUQ-BIIALRY/LLQ-COLONIC
    QUALITY AND INTENSITY: COLICKY VS OTHER
    RADIATION : TO BACK -PANCREATIC,R SHOULDER-GALL BLADDER
    AGG FACTR /ALLEVAITING FACTROS : FOOD /EMPTY SOTMACH/BOWL MOVEMENTS/RX
    ASSOCIATED : REFLUX SYMPX(RETROSTERNAL BURNING ,ACID BRASH ,WORSE ON LYING FLAT –GERD
    ),EXERTIONAL DYSPNEA ,OR CHEDT PSIN
    EXXCLUDE CARDIAC VS GERD VS PANCREASE VS BILIARY VS COLONIC
    NOCTURNAL SYMPTOMS (SLEEP POSTURE, LATE DAY EATING )

    EXXLUDE `ALARM FEATURS:


    DEWJAV PREVIOUS: DYSPHAGIA, EARLY SATIETY,WT LOSS,JAUNDICE,ANEMIA,VOMITING,PREVIOUS GSTRIC
    ISSUES

    PAST MEDICAL: GASTRIC ,PANCREATC,BIILIARY ,COLONIC ISSUES/CANCERS/HXX OF


    ANEMIA,HYPERLIPIDEMIA,

    MEDICATIONS: ANY PPI USE BEFORE ,COMPLIANCE,DRUGS CAUSING GERD


    (NITRAT,CCB,BISPHOSPHONATES,THEOPHYLLIN ) ,DRUGS CAUSING GSTRIC ISSUE
    (NSAIDS,STEROIDS,BISPHOPHTS) ,DRUGS CAUSING PACNREATITIS ( AZATHIOPRINE,HIV DRUGS,LOOP AND
    THIAZIDE DIURETICS )

    SOCIAL ISSUES : ALCOHAL ,SMOKING ,LIFESTYLE ,OBESITY


    IMPACT OF SYMPTOMS ON LIFE,JOB ETC

    Change in bowl habit : what is the trouble with your bowl habits -diarrhea ( >200 GM/DAY STOOL/VERY
    LOOSE STOOL ) /constipation(<3 BM /WEEK)  can you tell me exactly what do u mean by
    constipation/diarrhea/loose stool --how is diff. from your normal bowl habits WHAT IS YOUR NORML
    BOWL HABIT ( HOW OFTEN YOU OPEN YOUR BOWL IN AVG WEEK

    CONSTIPATION:WHAT DO U PASSSTOOL HARD /SOFT DOES IT HURT WHEN U PASS IT ANY BLOOD IN
    STOOL /TOILET AFTER FINISH,STILL HABE THE FEELING TO OPEN BOWLS -ARE YOU STILL PASSING WIND
    DO YOU EVER LOOS CONTROL OF YOUR BOWLS. R/O DEFECATORY DISORDER :SENSITIVE QS1.DO YOU
    EVER HAD DIFF PASSING SOFT AS WELL AS HARD STOOLS 2.DO YOU EVER FIND IT DIFF TO RELAX IN ORDER TO
    PASS STOOLS 3.DO YOU EVER NEED TO PUT FINGER IN YOUR back passage TO HELP YOU PASS STOOL

    DIARRHEA:
    OCDPAE
    QUALITY :WATERY : LARGE VOLUME ( SECRETORY),MOD VOLUME ( OSMOTICM)
    BLOOD DIARRHA+ TUMMY PAIN :INFLAMMATORY
    PALE GREASY STOOL ;WT LOSS- MALABSORPTION
    URGENCY :PROCTITIS
    ANY NIGHT SYMPTOMS
    IMPACT ON JOB AND TRAVEL(ANY PAD DURING TRAVEL)
    RELIEVING FACTR:AGGROVTING FACTRS ( FOOD : CELIAC VS LACTOSE )
    ASSOCIATED SYMPTOMS:1.ABDOMINAL SYMPTOMS ( N,V,DYSPHAGIA,REFLUX,TUMMY PAIN,WT LOSS),2.
    EXTRAINESTINAL SYMPTOMS ( JOINT PAIN ,RASH ,EYE ,ORAL ULCERS),SYSTEMIC ( FEVER
    ,FATIGUE,LUMPS+BUMPS)
    ANY RECENT RX ( ANTIBIOTIC WITHIN 2 MONTHS ) ,ANY RECENT CONTACT WITH ILL,RECENT FOOD FROM
    OUTSIDE ,TIME B/W FOOD AND SYMPTOMS ( <6HR STAPH,8-14 HR  CLOS PERFRINGS,>14 HR VIRAL)

    PAST MEDICAL: CONSTIPATION : HYPOTHY+INC CA+PREVIOUS SPINALCARD SURGERY +DIVERTICULOSIS,,


    DIARRHEA : T2DM,CHR PANCREATITIS,HYPERTHYROID,CELIAC ( AA FOR GRAVE ),SYSTMC SCLEORIS,CAFCINOID

    MEDICATIONS ; DIARRHEA (AB+ACE INH+DIGOX+SSRI+STATIN+PPI+LAXA+MG)

    SOCIAL ISSUES :ALCOHAL(PANCREASE ) /SMOKING ( CROHN FLARE )/DIETRY /HIV R/F/ANAL INTERCOURSE

    You might also like