History of gall bladder diseases

Name

Age

Sex

Occupation

Residence

Marital status

Date of admission

C/o

Rt upper quadrant pain for 1 day

HPI:

● Right hypochondrial pain:Onset, Duration , character, severity ,radiation , relieving and aggravating factors and  Association

● Fever onset .duration .day or night . High or low. Intermittent or constant .relieving factors

● Jaundice :     Onset , Progression ,intermittent or constant . How was noticed .degree of jaundice(deep yellow or light yellow).

Vomiting :Onset , Number of times. Projectile .Relation to food .Containing old food. Odor.   effortless or associated with Ritching , Association  with anorexia or nausea.

Upper GIT symptoms

Dysphagia  :   Onset ,To solid or liquid , Progression,level and compensation
Heart burn :  Onest , During day or night , relieving and aggravating factors

Easy satiety. Bloating , belching,Nausea and vomiting

Stool : colour (melaena- fresh blood), Amount containing blood clots .constipation or diarrhoea , when did it stopped

Symptoms of malignancy:

Weight loss 

symptoms of anemia (Fatigability , SOB and palpitation on exertion ).

Symptoms of metastasis: 

● GIT :abdominal distension.

● CVS + Respiratory:cough with haemoptysis chest pain lower limb edema.

● CNS:loss of consciousness . Headache . Convulsion .

● Genitourinary:urine amount colour and frequency

● Menstrual cycle: menorrhagea- Number of children - use of contraceptive pills

Fill the gap

●  e.g seen in x Centre received management .U/s was done

Past Medical History:

● Hospitalization

● Surgical operation

● Endoscopy or ERCP : when, how many time, was  diagnostic biopsy taken .if they did  stenting . Post procedure complications , followup and diagnosis .

● Blood transfusion

● History of anemia.

● History of jaundice or contact with patient with jaundice or hepatitis

● History of sickle cell anemia or hematological disease

Family History :

Similar condition

Family history of sickle cell disease

Family history of other malignancies

Drug History:

Long term medication

Social History :

Home condition

Water and electricity

Level of education

Smoking

Alcohol abuser

Health insurance

Nutritional Habits