History Taking Skills Gastrointestinal System

Introductory Course, 2011-2012

Khaled Jadallah, MD

Learning Objectives

Essentials for proper history taking Common GI symptoms Features of most common GI symptoms

Outline for the Interview

The Opening
Chief Complaint(s) History of Present Illness (HPI)
Primary Secondary (focused ROS): associated symptoms Tertiary (focused PMH)

Review of Systems Past Medical History

The other Pieces of the Puzzle

Past medical history Surgical history Drug history Social/occupational history Family history

GI Symptoms
Halitosis Mouth sores Water brash Heartburn Odynophagia/dysphagia Globus Anorexia Nausea Vomiting Weight loss Abdominal pain Abdominal bloating Increase in abdominal girth Early satiety Postprandial fullness Indigestion/dyspepsia Diarrhea Constipation Tenesmus Anal pain or pruritis Proctalgia fugax Jaundice

Signs of GI Diseases
General manifestations Eye manifestations Oral/dental manifestations Skin/mucous membranes manifestations Cardiovascular Pulmonary Hematolgical Endocrine Renal/urinary Musculoskeletal Neurological

Weight Loss

Abnormal Skin and Mucus Membranes

Aphthous Ulcer

Leukoplakia

Lead poisoning

Spider Naevi

PAN

Porphyria cutanea tarda

Carcinoid Flush

Grey - Turner sign

Cullens sign

Gynecomastia

Hand and Nail Abnormalities

Astrexia

Terry's nails Seen in liver cirrhosis. White proximal nail, reddened distal nail

Leukonychia (White nails) hypoalbuminaemia or chronic renal failure.

Palmar erythema
CLD, pregnancy, OCD use, RA and thyrotoxicosis

Caput Medusae Describes the appearance of distended and engorged umbilical veins which are seen radiating from the umbilicus across the abdomen to join systemic veins.

Dysphagia
Difficulty in swallowing Food or liquid sticking Wont go down right

Where the dysphagia is felt ? When did it start ? Is it intermittent or persistent ? What precipitate it ? Solid or Liquid ? Hot or Cold ?

Achalasia

Diffuse Esophageal Spasm

Nausea and Vomiting

 Nausea:
feeling sick to my stomach

Vomiting:
Forceful expulsion of gastric content out of the stomach

Regurgitation:
Raising of gastric or esophageal material out of the stomach in the absence of nausea

Details needed -color -content -smell -estimated amount -relation to eating

Abnormal Bowel Movements

Bowel Movement
Frequency:
Three times a day to two times a week

Volume Color and contents

Blood, dark, frothy, mucus, greasy

Difficulty in straining/ painful defecation Smell !! Tenesmus

Constipation

Diarrhea

Watery Diarrhea
Volume, frequency, contents, chronicity..

Steatorrhea
Pale, floats and sticky

Massive lower GI bleeding

Abdominal Distension

Abdominal Pain

Abdominal Pain
Visceral pain:
Originates from abdominal organs Poorly localized Near the midline

Parietal pain:
Originates from parietal peritoneum More localized over the involved organ

Referred pain:
Well localized Distant to the site of original organ

Abdominal Pain
Visceral pain:
Originates from abdominal organs Poorly localized Near the midline

Parietal pain:
Originates from parietal peritoneum More localized over the involved organ

Referred pain:
Well localized Distant to the site of original organ

Abdominal Pain
Visceral pain:
Originates from abdominal organs Poorly localized Near the midline

Parietal pain:
Originates from parietal peritoneum More localized over the involved organ

Referred pain:
Well localized Distant to the site of original organ

Abdominal Pain
Visceral pain:
Originates from abdominal organs Poorly localized Near the midline

Parietal pain:
Originates from parietal peritoneum More localized over the involved organ

Referred pain:
Well localized Distant to the site of original organ


Avicenna

 Where does the pain start ? Does it travel anywhere ?

 Timing of the pain

Acute or chronic Gradual or sudden When did it start How long did it last What is the pattern over the last 24 hours

 How severe is the pain ?

Not that helpful in identifying the cause of pain. Cultural differences Severity tend to diminish with age

 Quality of pain ?
Colicky/Cramping : suggest pain related to
peristalsis

Heartburn: acid reflux Sharp / stabbing: pancreatic Dull / aching: non-specific

 What aggravates or relieves the pain ?

Eating Medications Emotional factors Posture or activity Body functions: defecation, menstruation or urination.

Anal Problems

Take-Home Points
General

Be organized!! Begin each medical interview with a patient-centered approach Use open-ended questions initially Work hard to develop effective doctor-patient communication skills

 GI complaints can be vague and confusing When confronted with a patient complaining of abdominal pain, the provider must first rule out catastrophic causes of pain Do not let the location of abdominal pain affect the breadth of your history taking Remember! GI problems can manifest with extra-GI symptoms, and, extra-GI problems can manifest with GI symptoms

Take-Home Points GI System

On-Line Resources
http://www.qub.ac.uk/cskills/video%20re source/GI%20history.htm http://www.meddean.luc.edu/lumen/med ed/MEDICINE/PULMONAR/PD/content s.htm