Hepatobiliary system

{Hepatobiliary system}

[+] yes, present, positive
[-] no, absent, negative
[~] equivocal
[\] not applicable, not performed
[?] unknown, unsure, unavailable
{ } annotation, comment
      
PRESENTING COMPLAINTS OR ISSUES
Reasons for visit:
[-] new problem/issue
[-] review/follow-up

Presenting symptoms:
[-] jaundice
[-] dark urine
[-] steatorrhoea
[-] pale stools
[-] pruritus

[-] fever
[-] nausea
[-] vomiting

[-] abdominal pain
  Pain location: 
  [-] RUQ, [-] epigastric, [-] LUQ
  [-] R Loin, [-] central, [-] L Loin
  [-] RLQ, [-] suprapubic, [-] LLQ

Pain details:
    Onset: 
    Frequency: 
    Quality: 
    Radiation: 
    Severity /10: 
    Aggravating factors: 
    Relieving factors:

[-] abdominal bloating

[-] flatulence
[-] diarrhoea
[-] constipation
[-] altered bowel habit
[-] haematemesis
[-] PR bleeding
[-] melaena

[-] anorexia
[-] weight loss
[-] weight gain

History of presenting complaint:
  Onset: 
  Location: 
  Severity (/10): 
  Quality: 
  Timing: 
  Context: 
  Aggravated by: 
  Relieved by:

Associated symptoms:
[+] 
[-]

Treatment to date:
-

Diagnostic investigation results:
[+] 
[~] 
[-] 
[?]

PAST MEDICAL HISTORY
Relevant past medical history:
[-] hepatitis, type: 
[-] jaundice
[-] blood transfusions
[-] intravenous drug use
[-] tattoos
[-] STIs, details: 
[-] abdominal surgery
[-] oral contraceptive use

SOCIAL HISTORY
Alcohol intake:
[-] nil
[-] alcohol use
  If yes, standard drinks per week:

Occupational History: 
[-] organic solvent exposure
[-] work with animals, details:

FAMILY HISTORY
Relevant family history:
[-] haemochromatosis
[-] genetic liver disease (eg Wilson disease)
[?] 
[-]

PHYSICAL EXAMINATION
Relevant examination findings:
  Heart rate (bpm): 
  Blood pressure (mmHg): 
  Temperature (deg.C):

Height (m): 
  Weight (kg): 
  BMI (weight/height^2):

[-] jaundice 
[-] caput medusae
[-] hepatomegaly
[-] splenomegaly
[-] ascites
[-] abdominal tenderness, location/s:

Investigation Results:

ASSESSMENT
Clinical summary:
[+] 
[~] 
[-]

Diagnosis/es:
1. 
2.

Differential diagnosis:
-

MANAGEMENT PLAN
Procedures performed:
-

Diagnostic investigations requested:
-

Referrals:
-

patient information and advice:
-

Medication:
-

FOLLOW-UP
Outstanding issues:
-

Next appointment:
-

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Hepatobiliary system

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