Medical History Taking in Gastroenterology & Hepatology Mohssen Nassiri Toosi, MD

Medical History Taking in GI & Liver Disease What is the purpose of medical history taking? Patient introduction Patient main problem understanding Patient problem solving approach Patient medical differential diagnosis Patient problem treatment Patient satisfaction

Medical History Taking in GI & Liver Disease Types of medical history taking Emergent situations Cover patient life first Out-patient situation Cover brief, focused, and problem-oriented history In-Patient situation Cover comprehensive history

Medical History Taking in GI & Liver Disease Types of medical history taking Emergent situations Know emergent situations Think about emergent situation Understand emergent situation on a patient Do emergent actions to cover life Take emergently-needed history Resuscitate emergent condition Take complete comprehensive history

Medical History Taking in GI & Liver Disease Types of medical history taking What are Emergent situations Life-threatening situations A irways problems Severe dysphagia and breathing problem due to Food impaction B reathing problems Severe chest pain and dyspnea due to Diaphragmatic hernia Abdominal pain, hypotension and dyspnea due to hydatid cyst rupture anaphylaxis C irculation problems GI bleeding and severe blood loss (massive) Abdominal pain and shock

Medical History Taking in GI & Liver Disease Emergent medical history taking Secure airway, breathing, and circulation Control vital signs Open veins for IV access Take blood sample for examination Take history to assess severity (Assessment) Start Resucitation and emergent treatments Start problem-base history taking

Medical History Taking in GI & Liver Disease Emergent medical history taking in GI bleeding Assessment BP, orthostatic change, PR, skin and mocosa, Urine output CBC, PLT, BUN, Creatinie, PT (INR), ABO blood group Resucitation IV fluid, Oxygen, Appropriate blood product Start problem-base history taking PUD, Retching, Drug (ASA) intake, Malignancy,Liver diasease, surgery, ….

Medical History Taking in GI & Liver Disease Types of medical history taking Out-patient situation Cover briefly focused, problem-oriented history There is no emergent situation. Patient is in a stable condition. This is the first visite. You know the patient from before. You have less time for each patient.

Medical History Taking in GI & Liver Disease Parts of a medical history Identifications (patient ID) Chife complaint Present illness Past medical history Review of system Physical examination Problem list Differential diagnosis

Medical History Taking in GI & Liver Disease Parts of a medical history Identifications (patient ID) name age gender birth place ethinicity occupation education level marrigae status family size Religious …….

Medical History Taking in GI & Liver Disease Parts of a medical history Identifications (patient ID) What is its purpose? Patient introduction better Patient-problem solving approach better Patient-problem treatment

Medical History Taking in GI & Liver Disease Parts of a medical history Identifications (patient ID) Chife complaint (CC)

Medical History Taking in GI & Liver Disease Parts of a medical history Identifications (patient ID) Chife complaint (CC) What is CC? The main cause of referring patient to doctor Usually single ( but sometimes more than one ) By patient, s words ( but be sure it is reliable )

Medical History Taking in GI & Liver Disease Parts of a medical history Identifications (patient ID) Chife complaint (CC) What is CC? The main cause of referring patient to doctor and the most important complaint for patient Patient usually has many complaints Sometimes it is more than one The main request of patient is important Sometimes it is not a physical complaint

Medical History Taking in GI & Liver Disease Parts of a medical history Identifications (patient ID) Chife complaint (CC) What is CC? The main cause of referring patient to doctor Usually single To be main and major not accessory ones Sometimes it is multiple Make a syndrome from multiple CCs

Medical History Taking in GI & Liver Disease Parts of a medical history Chife complaint (CC) Make a syndrome from multiple CCs Jaundice Fever Chills Abdominal pain Jaundice melena Sever abdominal pain Interactible vometing

Medical History Taking in GI & Liver Disease Parts of a medical history Identifications (patient ID) Chife complaint (CC) What is CC? The main cause of referring patient to doctor Usually single By patient, s words Not by physician interpretation but by physician guidence Patient, s words must be reliable and correct It need mutual conversation and dialoge

Medical History Taking in GI & Liver Disease Natural eventPatient thinkingTrue event Pale & YellowishnessjaundicePaleness Decreasing defecationsLiver diseaseconstipation Sensation of food in the throatDysphagiaglobus sensation Dark stoolGI bleeding Constipated faeces, Drug (bismuth) or food Epigastric distention Bowel obstruction or ulcer bloating

Medical History Taking in GI & Liver Disease Parts of a medical history Identifications (patient ID) Chife complaint Present illness What is present illness? It is to understand better CC. It consists of all medical history related to CC. It could include all PMH, DHx, and Lab tests, except physical examination. It must clear and describe all medcial aspects of CC. It is main part of medical history. It must lead to differential diagnosis.

Medical History Taking in GI & Liver Disease Parts of a medical history Identifications (patient ID) Chife complaint Present illness Levels of present illness Level 1 Level 2 Level 3

Medical History Taking in GI & Liver Disease Parts of a medical history Present illness Levels of present illness Level 1 Patient talk and doctor listen Let patient feels free Guide patient to talk about CC It is like a story of CC from patient side Do not take many time and do not need special knowledge

Medical History Taking in GI & Liver Disease Parts of a medical history Present illness Levels of present illness Level 2 Doctor make fixed question and patient make answer Base on a prototype questions to describe CC Can change in different CC Location, radiation, timing, aggrevating factors, relieving factors, relations, associations, changing through time Try to describe CC completely Need medical knowledge Prepare for starting differential diagnosis

Medical History Taking in GI & Liver Disease Parts of a medical history Present illness Levels of present illness Level 3 Doctor make oriented question and patient make answer Base on speculated differential diagnosis (D.Dx) Need generation of differential diagnosis Need knowledge and study on each D.Dx Need generation of DD-oriented questions D.Dx are completed in progress

Medical History Taking in GI & Liver Disease Parts of a medical history Identifications (patient ID) Chife complaint Present illness Past medical history Review of system Physical examination Problem list Differential diagnosis D.Dx

Medical History Taking in GI & Liver Disease Levels of a present illness Level 1 Patient story about CC Patient talk, doctor listen Level 2 Medical description of CC Fixed questions about CC Level 3 Completing present illness D.Dx oriented questions Better understanding CC Starting D.Dx Complete D.Dx