GI History Introductory

History Taking SkillsGastrointestinal

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

• “Won’t 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 organsOriginates from abdominal organs– Poorly localizedPoorly localized– Near the midlineNear the midline

• Parietal pain:– Originates from parietal peritoneumOriginates from parietal peritoneum– More localized over the involved organMore localized over the involved organ

• Referred pain:– Well localizedWell localized– Distant to the site of original organDistant to the site of original organ

Abdominal Pain

• Visceral pain:– Originates from abdominal organs– Poorly localized– Near the midline

• Parietal pain:Parietal pain:– Originates from parietal peritoneumOriginates from parietal peritoneum– More localized over the involved organMore localized over the involved organ

• Referred pain:Referred pain:– Well localizedWell localized– Distant to the site of original organDistant to the site of original organ

Abdominal Pain

• Visceral pain:Visceral pain:– Originates from abdominal organsOriginates from abdominal organs– Poorly localizedPoorly localized– Near the midlineNear the midline

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

• Referred pain:Referred pain:– Well localizedWell localized– Distant to the site of original organDistant to the site of original organ

Abdominal Pain

• Visceral pain:Visceral pain:– Originates from abdominal organsOriginates from abdominal organs– Poorly localizedPoorly localized– Near the midlineNear the midline

• Parietal pain:Parietal pain:– Originates from parietal peritoneumOriginates from parietal peritoneum– More localized over the involved organMore localized over the involved organ

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

القولنج كتابAvicenna

الله عبد ابن الحسين على ابوسينا ابن

• 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 PointsGeneral

• 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

Take-Home PointsGI System

• 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

On-Line Resources

• http://www.qub.ac.uk/cskills/video%20resource/GI%20history.htm

• http://www.meddean.luc.edu/lumen/meded/MEDICINE/PULMONAR/PD/contents.htm