Colo-rectal History

Name

Age

Sex

Occupation

Residence

Marital status

Date of admission

C/O

Lower rectal bleeding /months

HPI

Bleeding per rectum :onset, times ,amount, colour(bright red,Marron coloured or black),containing blood clot,relation to stool (before ,after or within the stool),stain the underwear, stain toilet papers ,associated with mucous .the effect of bleeding (loss of consciousness , palpitation and shortness of breathing),required hospitalization(on his fee , was supported by others, types of management done for him) ,stopped spontaneously or by intervention

pain onset .site  (anal .deep rectal .abdominal ),duration, severity,character,radiation ,relieving and aggravating factors,association

Bowel habits :The normal habits, number of time ,constipation or diarrhoea ,containing mucous

Symptoms of rectosigmoid tumour

Change in bowel habit 

Calibrated stool

spurious diarrhoea

Incontinence

Delayed passage of stool

feeling of Mass per rectum

feeling of abnormal opening around the anus

Sense of incomplete emptying

Tenesmus

Post defecation soiling

Symptoms of left side colon

Vomiting

Abdominal distension

Absolute constipation

left sided pain

Symptoms of right  sided colon

Abdominal mass:onset. initial size . How it was noticed  .progression and pain

Symptoms of anemia(fatigability,palpitation and Shortness of breathing on exertion)

  wt loss

Fever with sweating

Upper GIT bleeding

Heart burn and Haematemesis

Symptoms of metastesis

GIT :jaundice. abdominal distension

CVS+ respiratory :cough with haemptosis chest pain lower limb oedema

CNS:loss of conciousness . Headache . Convulsion 

Urinary: urine amount colour and frequency, haematouria ,pnematouria and fecalour    

Fill the gap

e.g Seen in x Centre received management .done endoscopy and biopsy

Past Medical History:

 Hospitalization

 Surgical operation

 Endoscopy or colonoscopy : when, how many time, was diagnostic take biopsy  results . Post procedure followup and diagnosis .

Blood transfusion

 History of anemia.

History of Inflammatory bowel diseases

 History of schistosmiasis and Dysentery.

Family History   :

Similar condition

Family history of malignancies

Drug History:

Long term medication (Pentasa - steroids .etc)

History of chemo radiotherapy.

History of use of aspirin or anticoagulants

Social History:

Home condition

Water and electricity

Level of education

Smoker

Alcohol abuser

Health Insurance

Nutritional Habits