Surgical History and Physical Examination Identifying Data: Patient’s name, age, race, sex; referring physician. Chief Compliant: Reason given by patient for seeking surgical care and the duration of the symptom.
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History of Present Illness (HPI): Describe the course of the patient’s illness, including when it began, character of the symptoms; pain onset (gradual or rapid), precise character of pain (constant, intermittent, cramping, stabbing, radiating); other factors associated with pain (defecation, urination, eating, strenuous activities); location where the symptoms began; aggravating or relieving factors.
Vomiting (color, character, blood, coffee-ground emesis, frequency, associated pain). Change in bowel habits; rectal bleeding, character of blood (clots, bright or dark red), trauma; recent weight loss or anorexia; other related diseases; past diagnostic testing. Past Medical History (PMH): Previous operations and indications; dates and types of procedures; serious injuries, hospitalizations; diabetes, hypertension, peptic ulcer disease, asthma, heart disease; hernia, gallstones. Medications: Aspirin, anticoagulants, hypertensive and cardiac medications, diuretics. Allergies: Penicillin, codeine, iodine. Family History: Medical problems in relatives. Family history of colon cancer, cardiovascular disease. Social History: Alcohol, smoking, drug usage, occupation, daily activity. Review of Systems (ROS): General: Weight gain or loss; loss of appetite, fever, fatigue, night sweats.
Activity level. HEENT: Headaches, seizures, sore throat, masses, dentures. Respiratory: Cough, sputum, hemoptysis, dyspnea on exertion, ability to walk up flight of stairs. Cardiovascular: Chest pain, orthopnea, claudication, extremity edema. Gastrointestinal: Dysphagia, vomiting, abdominal pain, hematemesis, melena (black tarry stools), hematochezia (bright red blood per rectum), constipation, change in bowel habits; hernia, hemorrhoids, gallstones. Genitourinary: Dysuria, hesitancy, hematuria, discharge; impotence, prostate problems, urinary frequency. Gynecological: Last menstrual period, gravida, para, abortions, length of regular cycle and periods, birth control. Skin: Easy bruising, bleeding tendencies. Neurological: Stroke, transient ischemic attacks, weakness.
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