Description:

Form from HIS OpenVista

Keywords:
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  2. 8/7/14
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  4. 12/23/14
  5. 6/25/15
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June 25, 2015

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License:
Creative Commons BY-NC 3.0 Legacy
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SHORT STAY RECORD ID NOTE-ENDO

HIS

  1. StudyEvent: HIS
    1. HIS
SHORT STAY RECORD ID NOTE-ENDO
years
Sex
cm
kg
Chief complaint (CC)
Abnormal GI Xray
Abdominal Pain
Abnormal weight loss (finding)
Achalasia
Anaemia
Ascites
Irregular bowel habits
Liver Cirrhosis
Screening for Colorectal Cancer
Common Bile Duct Leak
Common Bile Duct Stone
Constipation
Diarrhea
Indigestion
Deglutition Disorders
Elevated Liver Function Tests
Oesophageal Varices
Family History of Colon Cancer
Family History of Polyps
Family History of Polyposis
Foreign Body in Colon
Foreign Body in Esophagus
Foreign Body in Stomach
Peptic Ulcer
Gastroesophageal reflux disease (GERD)
Gastrointestinal Hemorrhage
Haematemesis
History of Barrett's
History of Cholangiocarcinoma
History of Colon Cancer
History of Crohn's Disease
History of Diverticulosis
History of Esophageal Cancer
History of Esophageal/ Gastric Varicies
History of Gastric Cancer
History of Pancreatic Cancer
History of Peptic Ulcer Disease
History of Polyps
History of Ulcerative Colitis
Blood in Stool
Iron Deficiency Anaemia
Icterus
Melaena
Nausea
Emesis
Occult/Guaiac Positive Stool
Pancreatitis
Portal Hypertension
gastric reflux
Abnormal weight loss
Physical examination
°C
beats/minute
/min
mmHg
General Apperance unremarkable
HEENT within normal limits
Neck supple, no jugular vein distention
Heart S1 S2 present, Regular rhythm and rate
Abdomen Soft, (+) Bowel sounds, Normal tone
Lymph Nodes not palpable
Extremities No clubbing, cyanosis or edema
Skin: No abnormalities detected
Neurological: No abnormalities detected
Teeth
Mallampati score
past medical History, prior medical History