history taking skills gastrointestinal system

1. History Taking SkillsGastrointestinal System Khaled Jadallah, MD

3. Objectives of History Taking The primary goal of any history taking is to aid the clinician in establishing a diagnosis (or a list of diagnostic possibilities) It has been estimate that over 70% of diagnoses can be made on history alone History taking also has other objectives: It allows the doctor to develop a rapport with their patient, place the patient�s diagnosis in the context of their life, and highlight important physical signs that need to be sought on physical examination

4. 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

5. PRESENTING COMPLAINT This may be achieved by asking for e.g. �What problems brought you to the doctors today?� Use the patient�s own words to describe the chief complaint The chief complaint and associated symptoms/signs or lab/imaging findings constitute the �clinical problem�

6. The other Pieces of the Puzzle Past medical history Surgical history Drug history Social/occupational history Family history

7. Common GI Symptoms Globus Waterbrash/sourbrash Heartburn Odynophagia Dysphagia Dyspepsia Nausea Sitophobia Vomiting Anorexia Retching Belching Jaundice Painful mouth ulcers Constipation Obstipation Diarrhea Tenesmus Anal pruritis Rectal pain/proctalgia fugax Weight loss Abdominal pain Hematemesis Melena Hematochezia Increase in abdominal girth Bloating/aerophagia

8. Abdominal Pain Third most common complaint of humans Most common cause of GI consultation Can be Hyperacute Acute Subacute Chronic/relapsing

9. Abdominal Pain Visceral Pain - crampy, diffuse, aching Somatic Pain � localized, intense, sharp � from irritation of peritoneum Referred - pain from problem in another area Mapping pain may be crucial in initial diagnosis and tests

10. Types of Abdominal Pain Pain from peritoneal irritation � this type of pain is more ominous and is associated with peritonitis of any sort This pain is generally: Steady/constant Often well localized Not related to peristalsis Patient often lies still with knees up

11. Referred Pain Abdominal pain is not always confined to the abdomen Perforated ulcer � can radiate to the shoulder region Biliary colic � can radiated to the scapula/shoulder region Renal colic � can radiate to the flank and/or scrotum Dysmenorrhoea � can radiate to the lower back

12. Features of Abdominal Pain First episode or similar attacks?? Location Onset Duration Frequency Nature/character Severity Relation to food ingestion Aggravating factors Relieving factors Radiation Associated symptoms Last bowel movement Effect on function

13. History..What Questions to Ask? Where is your pain? Has it always been there? Does the pain radiate anywhere? How did the pain begin (sudden vs. gradual onset)? How long have you had the pain? What were you doing when the pain began? What does the pain feel like? On a scale of 0�10, how severe is the pain? Does anything make the pain better or worse? Have you had the pain before?

15. The �Digestive� Pain Digestive tract pain is generally midline Abdominal pain which is localized to either side suggests that the pain originates from organs with innervation which is predominantly one-sided (e.g. kidneys, ureters and ovaries), or structures with somatic innervation

16. Common Conditions Mimicking Acute Abdomen Pneumonia Angina or MI Obstructive Uropathy Hepatitis Sickle cell crisis Leukemia Radiculopathy Cystitis Poisons/toxins Prostatitis Pyelonephritis Ureteral obstruction Vasculitis Abdominal wall hematoma Psychogenic Pericarditis Herpes Zoster Acute intermittent porphyria

17. The Acute Abdomen The term �acute abdomen� is usually reserved for a clinical situation in which the patient is suddenly incapacitated by very intense abdominal pain which may or may not be associated with fever, nausea, vomiting or shock Diagnosis and management depends on information derived both from the history and from the examination.

18. Characteristics of Abdominal Painin Common Surgical Conditions Acute appendicitis Acute cholecystitis Perforated ulcer Small bowel obstruction Large bowel obstruction Biliary �colic� Renal colic Dissecting/rupture abdominal aneurysm Rupture ectopic pregnancy Mesenteric infarction Abdominal apoplexy (ruptured spleen or liver)

19. Appendicitis Epigastric pain, loss of appetite with or without nausea and vomiting, pain shifting to right lower quadrant

20. Acute Cholecystitis Right upper quadrant or epigastric pain with or without radiation to the back, loss of appetite with or without nausea and vomiting Previous similar symptoms common, fatty food intolerance common

21. Perforated Ulcer Sudden catastrophic abdominal pain with gradual improvement Past history of ulcer disease in 50% of cases

22. Small Intestinal Obstruction Cramping abdominal pain, the vomiting of large quantities of fluid, obstipation Pain subsides after 24 hours of complete obstruction

23. Large Intestinal Obstruction (Carcinoma, Diverticulitis, Volvulus) Similar to small bowel obstruction Vomiting may be minimal if the ileocecal valve is competent (closed loop obstruction)

24. Biliary �Colic� Sudden onset of acute right upper quadrant or epigastric pain, with nausea, vomiting The pain is constant�..NOT colicky

25. Renal Calculus Severe abdominal pain, usually unilateral, centering on the flanks and radiating to the groin Can be associated with nausea and/or vomiting

26. Rupturing Abdominal Aneurysm Sudden onset of severe abdominal, back or flank pain with or without collapse Often positive history for other atherosclerotic problems Problem-focused history is a MUST

27. Ruptured Ectopic Pregnancy Complaints suggesting early pregnancy -- missed or abnormal period; diffuse lower abdominal pain

28. Mesenteric Infarction Severe diffuse abdominal pain with or without bloody bowel movement or collapse Cardiac history frequent

29. Abdominal Apoplexy(Ruptured Spleen, Liver or Blood Vessel) Diffuse abdominal pain, usually without nausea, vomiting. Collapse frequent History of trauma common

30. Acute vs Chronic Abdominal Pain While acute pain often appears to be more dramatic or serious than chronic pain, one should not assume that chronic pain is any less significant Patients with gastrointestinal malignancies may present with chronic pain as their primary complaint Pain which wakes a patient from their sleep or is acute in onset suggests possible strangulation or perforation of the bowel Pain which is gradual in onset suggests an inflammatory process, such as appendicitis, or an infectious process, such as an abscess

31. 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

32. 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

33. 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