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
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
