1. History – Gastrointestinal system

2. Symptoms Anorexia Weight loss Painful mouth Dysphagia Heartburn & reflux Dyspepsia Nausea & vomiting Haematemesis & melaena Abdominal pain Wind & flatulence Altered bowel habit Rectal bleeding Jaundice

3. Anorexia & weight loss Anorexia –Systemic disease –Malignancy (usually late feature) Weight loss (reduced caloric intake – 500 Kcal deficit per day = 0.5 kg loss per week) –Anorexia –Malabsorption –Diabetes (energy loss due to glycosuria) –Hyperthyroidism (increased energy expenditure)

4. Painful mouth Idiopathic –Aphthous ulcers Infections –Candidiasis –HSV –Coxsackie virus Misc –Leucoplakia –Trauma from teeth/ill-fitting dentures Skin disease –Lichen planus –Pemphigoid, pemphigus vulgaris

5. Painful mouth Systemic disease –Drug allergies – Sulphonamides, cytotoxics –Iron, folate, B12 deficiency –Acute leukaemia (leucopenia) –Inflammatory bowel disease

6. Dysphagia Oral –Mouth ulcers –Tonsilitis, pharyngitis –Peritonsillar abscess Neurological (liquids > solids) –CVA –Bulbar & pseudobulbar palsy Choking, regurgitation

7. Dysphagia Neuromuscular (solids > liquids) –Achalasia –Myasthenia gravis Mechanical (strictures) –Malignancy –Oesophagitis

8. Dysphagia Pain? Progressive? Duration? Previous history of heartburn Solids or liquids Level where food sticks regurgitation

9. Heartburn & reflux GORD/GERD Radiates upward Burning Occurs with lying flat Has to be differentiated from cardiac pain

10. Dyspepsia Peptic ulcer –Worse on empty stomach –Eased by eating –Nausea –Abdominal fullness worse after spicy/fatty meals

11. Nausea & vomiting Upper GI disorders Non GI causes –Drugs –Pregnancy –Diabetic ketoacidosis –Liver/renal failure –Vestibular disease –Raised intracranial pressure –After severe pain (MI)

12. Nausea/vomiting GI causes –Peptic ulcer –Intestinal obstruction Bile stained/non bile stained

13. Vomiting Medications With or without nausea Pain or dyspepsia Pain relieved by vomiting Relation to meal times Bile-stained?

14. Haematemesis / melaena Red – Fresh Coffee grounds – action of pepsin Vomiting fresh blood – above GI sphincter –Mallory Weiss

15. Melaena Upper GI bleed –Peptic ulcer, Mallory Weiss tear, varices Tarry stool Typical odour Drug history – Iron, NSAID. alcohol

16. Pain Parietal (localized) Visceral – deep seated, poorly localized Epigastric –Stomach, liver, pancreas Periumbilical –Small intestine

17. P ulcerBil colicAc. PancrR. colic Site Epigastr.Epi/R HypoEpi/L HypoLoin Onset GradualRapid incre.SuddenRapid incre. Character GnawingConstant Radiation BackBelow R scapula BackGroin Timing RemissionUnpred. Can enumerate Can Enumerate Discrete episode Duration <2 hrs4-24 hrs>24 hrs4-24 hrs ↑factor Stress, spice, NSAID, Alc. Unable to eatAlcohol, unable to eat ↓factor Food, vomit, antacids, Upright Severity Mild - modsevere

18. Non GI causes MI Dissection of aorta Pleurisy Herpes zoster Diabetes ketoacidosis Pelvic causes – salpingitis, tubal ectopic preg.

19. Distension Fat Flatus – obstruction Faeces – constipation (subacute obstruction) Fluid – ascites, ovarian tumors Fetus

20. Ascites Cirrhosis with portal HT Abdominal malignancy with peritoneal spread CHF Hypoproteinemia

21. Constipation Lack of diet fibre Irritable bowel synd Obstruction Drugs – opioids, iron Hypothyroidism Immobility - stroke

22. Diarrhoea Acute –GI –Drug induced Chronic –Irritable bowel –Inflammatory bowel disease –Giardiasis –Malignancy –Diabetes –Hyperthyroidism –Malabsorpiton

23. Rectal bleeding Hemorrhoids Anal fissure Colonic polyps Malignancy Inflammatory bowel disease Ischaemic colitis Diverticulitis

24. Jaundice Bil. > 3 mg/dl Prehepatic –Hemolysis –Pale lemon color –Stools and urine are normal

25. Hepatic jaundice –Dark urine –Stools normal colored Posthepatic –Pale stools –Dark urine

26. History for Jaundice Appetite/ wt loss Pain GI bleed Pruritus, dark urine Drug/alcohol Previous hepatitis Blood transfusions Sexual history Travel history Family history