Name / age / sex / occupation / address
CHIEF COMPLAINTS
HISTORY OF PRESENTING ILLNESS
H/o Abdomen pain
Duration
Site
Onset
Nature (continuous/intermittent)
Character (constant/colicky)
Radiation
Severity
Aggravating/relieving factors
Associated features (fever/nausea/ vomiting/ defecation)
H/o Abdominal distension:
Duration
Onset (insidious/acute)
Site (localized/uniform)
Progress
, H/o Vomiting/Blood in vomit
No of episodes
Duration
Projectile
Associated with nausea/ headache/ blurring of vision
Quantity
Character (colour/smell/blood streaks)
Associated with food intake
Associated features (pain/malena/hematemesis/ loss of consciousness)
H/o drug intake (NSAIDS, Steroids)
H/o Yellowish discoloration of eyes [sclera] and skin
H/o Leg swelling
H/o Breathlessness
H/o Chest pain
H/o Puffiness of face
H/o Frothy urine (Nephrotic syndrome)
H/o Itching
H/o Discoloration of urine
H/o Pain/Burning micturition
H/o Oliguria / polyuria
H/o Hematuria
H/o Increased frequency of stools
H/o Constipation/Obstipation
H/o Altered color of Stools: (dark/ tarry black/ pale/ with frank blood)
H/o Mass in abdomen
Site
Duration
Progression
Associated pain