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GI Assessment Patient Initials________________________ Age ____ Date completed _______________ Provide your information – unicorp essays

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GI Assessment
Patient Initials________________________ Age ____ Date completed _______________
Provide your information below and answer the questions with (x)-
Height: ________ Weight (approx.): ________
Chief Complaint
Present Health Status
Past health history
Have you ever noticed blood in stool? □ Yes □ No
If your answer is yes, answer the questions below; otherwise, go to question 2.
Bright red
Dark blood
Blood in the middle of stool
Blood on paper, apart from stool
Blood mixed with and apart from stool
I can’t identify the type of bleeding
How often does bleeding occur?
Every day
Once a week
Twice a week
Once a month
It has happened once, or it rarely occurs
Bleeding started when?
One week ago, or less
One month ago
Less than 3 months ago
One year ago
Bleeding amount:
Small amount
Large amount
When bleeding occurs, do you feel anything in the anus? Itching, pain, or increased volume (swelling or tumoration)?
Yes
No
What’s your usual intestinal habit like? (How often do you evacuate?).
Daily
Three times a week
More than once a day
Less than once a week
Twice a week
Your bowel is usually:
Constipated (hard stool)
Diarrhea
Alternates between diarrhea and constipation
Nothing abnormal
Has your intestinal habit changed lately?
Yes
No
If your answer is yes, how has it changed?
ANSWER ONLY IF IT HAS CHANGED
It’s more frequent (I evacuate more often)
Changed to diarrhea
It’s constipated
I’m losing stool
It’s urgent
Now I have fine stool
Do you see mucus (jelly-like substance) or pus in stool? □ Yes □ No
Do you have frequent stomachache or abdominal discomfort? □ Yes □ No
If you feel abdominal pain, where is the pain exactly? □ In lower abdomen □ In upper abdomen
Have you felt any pain, itching, burning or increase volume (tumoration) in the anus in the last months? □ Yes □ No
Have you lost appetite in the last months? □ Yes □ No
Have you been submitted to any blood test that showed anemia? □ Yes □ No
Have you felt constant weakness (tiredness) in the last months? □ Yes □ No
Do you have nauseas and/or vomiting? □ Yes □ No
Have you even been submitted to exams such as colonoscopy? □ Yes □ No
No Have you ever had intestinal polyps? □ Yes □ No
Regarding your close family members: parents, brothers/sisters and grandparents: Has any of them had cancer? □ Yes □ No
Where? □ Bowel □ Breast □ Stomach □ Ovary
Who had it? □ Parents □ Grandparents □ Brothers/Sisters □ Uncles/Aunts
Do you: □ Smoke? □ Drink alcohol regularly? □ Eat fats and fried food very often? □ Eat greens and fruits very often?
Have you ever had cancer? □ Yes □ No
Have you experienced any changes in appetite? □ Yes □ No
Have you experienced any weight gain or loss? □ Yes □ No
Have you experienced any difficulty swallowing? □ Yes □ No
Have you experienced any nausea or vomiting? □ Yes □ No
Have you experienced any abdominal pain? □ Yes □ No
If you have experienced abdominal pain, the pain assessments listed on the next page MUST be completed.
Physical Assessment
RLQ
RUQ
LUQ
LLQ
Inspection- any scars, masses, wounds noted? Is the skin intact? Color? Bulges? Masses? Hernias? Ascites?
Auscultation- were bowel sounds heard?
Normal
Hypoactive
Hyperactive
Absent
Abdominal bruit
Normal
Hypoactive
Hyperactive
Absent
Abdominal bruit
Normal
Hypoactive
Hyperactive
Absent
Abdominal bruit
Normal
Hypoactive
Hyperactive
Absent
Abdominal bruit
Percussion- percuss for general tympany, liver span, and splenic dullness.
Palpation- any pain/tenderness on palpation?
Pain
Tenderness
None
Pain
Tenderness
None
Pain
Tenderness
None
Pain
Tenderness
None
Abdominal Pain Muscle Tests
Iliopsoas Muscle Test: The iliopsoas muscle test is used most often when acute abdominal pain is present, and appendicitis is suspected.
When your patient is lying in the supine position ask him or her to lift their right leg straight up, flexing only at the hip.
Push down on the lower part of the thigh when your patient is trying to hold their leg up.
If the patient feels pain in the iliopsoas muscle (the right lower quadrant of the abdomen) the test is positive and may indicate a perforated or inflamed appendix.
Was this test needed?
□ Yes □ No
Was this test performed?
□ Yes □ No
If this test was performed, what was the finding?
□ Positive □ Negative
The Obturator: The obturator muscle test is also performed when acute abdominal pain is presented appendicitis is suspected.
When your patient is lying in the supine position ask him or her to lift their right leg straight up, flexing at the hip, and 90 degrees at the knee.
Hold the ankle and rotate the leg internally and externally.
If the patient feels pain in the area of the internal obturator muscle (the right lower quadrant of the abdomen and pelvis) the test is positive and may also indicate a perforated or inflamed appendix
Was this test needed?
□ Yes □ No
Was this test performed?
□ Yes □ No
If this test was performed, what was the finding?
□ Positive □ Negative
The Blumberg Sign: Blumberg Sign is also known as rebound abdominal tenderness.
Choose a site away from the suspected area of tenderness.
Holding your hand 90 degrees to the abdomen, press inward deeply, then release quickly.
Pain on release of pressure is an indicator of peritoneal irritation
Was this test needed?
□ Yes □ No
Was this test performed?
□ Yes □ No
If this test was performed, what was the finding?
□ Positive □ Negative

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