1. Gastrointestinal System History-Taking Skills
Khaled Jadallah, MD
Associate Professor of Medicine
Consultant Gastroenterologist & Hepatologist

3. General Considerations
Patient-Centered History
Patient's agenda
Symptom focus
Patient tells story
Physician-Centered History
Physician's agenda
Biomedical focus
Physician gathers data
Remember that there are two halves to each interview, patient-centered and physician-centered. They are both important components of the interview.

4. Outline for the interview
The Opening
Chief Complaint(s) (CC)
History of Present Illness (HPI)
Primary
Secondary (focused ROS)
Tertiary (focused PMH)
Review of Systems (ROS)
Past Medical History (PMH)
This applies to history taking of any organ system

5. History of Present Illness
Primary history
Chief complaint
Secondary history
Associated symptoms
Tertiary history
Pertinent PMH

6. Primary History
You should always begin the physician-centered phase of the interview with "WH" questions (where? what? when?) directed at the chief complaint(s).
Build on the information the patient has already given you.
Flesh out areas of the story you don't fully understand.
Try to quantify whenever possible (pain on a scale of 1 to 10, number of days instead of "a while," etc.).
Be as specific as possible and try to record what the patient says accurately, without interpretation.

7. Primary History Example-Abdominal pain
Location
Radiation
Quality
Quantity
Duration
Frequency
Aggravating Factors
Relieving Factors
Associated Symptoms
Effect on Function
Address as many of these details as appropriate

8. Secondary History
Expands on the primary history, especially any associated symptoms.
It is useful to think of the secondary history as a focused review of systems.
These questions often bring out information that supports a certain diagnosis or helps you gauge the severity of the disorder.
Unlike the primary history, a certain amount of interpretation (and experience) is necessary.

9. Tertiary History
The tertiary history brings in elements of the past medical history that have direct bearing on the patient's condition.
By the time you get to the tertiary history you may already have a good idea of what might be going on. (This will be fine tuned by the physical exam)
Example: Abdominal Pain
Does the patient smoke? How much? How long?
How much alcohol does the patient consume?
Prior surgery? Has the appendix been removed?

10. Review of Systems As it relates to the GI problem
General/Constitutional
Skin/Breast
Eyes/Ears/Nose/Mouth/Throat
Cardiovascular
Respiratory
Genitourinary
Musculoskeletal
Neurologic/Psychiatric
Allergic/Immunologic/Lymphatic/Endocrine
Focus on any symptoms originating from other organ systems that my be related to the GI system. For example: dermatitis herpetiformis of celiac disease

11. Past Medical History Allergies and reactions to drugs (What happened?)
Current medications (including herbs)
Medical/Psychiatric Illnesses (Diabetes, Hypertension, Depression, etc.)
Surgeries/Injuries/Hospitalizations
Immunizations
Tobacco/Alcohol/Drug Use
Reproductive Status for Females
Last menstrual period
Pregnancies/Births/Contraception
Marital/Family status
Occupation/Exposures
The past medical history is essentially background information related to the patient's health and well being. A brief past medical (and social) history often inludes these elements.
A minimal interview consists of the chief complaint and primary history of present illness. The other elements may be selectively omitted as circumstances dictate. For example, a complete review of systems is often not necessary or desirable in the context of a focused evaluation.

13. GI Symptoms Halitosis Mouth sores Water brash Heartburn Regurgitation
Odynophagia
Dysphagia
Globus
Anorexia/sitophobia
Nausea
Vomiting
Weight loss
Abdominal pain
Abdominal bloating
Increase in abdominal girth
Early satiety
Postprandial fullness
“Indigestion”/dyspepsia
Hematemesis
Melena
Hematochezia
Diarrhea
Constipation
Obstipation
Tenesmus
Anal pain or pruritis
Jaundice

14. Problem-Based Learning
We treat patients, NOT diseases
The textbooks contain diseases, NOT patients
The patient desires to be treated in his wholeness, not as a disease
The practice of medicine takes a lot of reasoning, and NOT merely crude knowledge

15. A 43-year old man presents with the c/c of “difficulty swallowing”
Where is the dysphagia felt?
Is it a “transfer” (oropharungeal) dysphagia or
“transit” (esophageal) dysphagia??
Is it for solids or liquids only or for both solids and liquids??
Does it come even while not eating (bolus “hystericus”)?
When did it start? Is it intermittent or constant?
Any associated symptoms?
Chest pain
Heartburn/regurgitation
Chocking
Weight loss
Dry mouth/halitosis

16. Schatzki ring-Normal-Benign peptic stricture-Cancer

17. A 25-year old man with epigastric pain
A 25-year old man with epigastric pain. Take a problem-focused history and give your best differential diagnosis
Onset of pain
Duration of pain episodes
Character/nature of abdominal pain
Relation to food
Radiation
Relieving factors
Aggravating factors
Hx of similar episodes
Nocturnal symptoms
Any nausea or vomiting
Jaundice
Weight loss
Anorexia
Hematemesis
Melena
Bowel habits (constipation or diarrhea)
Dysphagia/heartburn/regurgitation
Drug history (NSAID, aspirin) / Smoking
Family history of PUD or GI cancer

19. A 58-year old male reports passing black stool for the last 2 days
A 58-year old male reports passing black stool for the last 2 days. Take a problem-focused history and give your most likely diagnosis
Frequency / Amount of melena
Dizziness
Hematemesis
Hx of abdominal pain
Character/nature of abdominal pain
Relieving / aggravating factors for abdominal pain
Dysphagia/heartburn/regurgitation
Hx of similar episodes
Hx of shortness of breath / chest pain
Weight loss / Anorexia
Other sites of bleeding (Hematuria / Epistaxis)
Hx. of hemorrhoids
Hx of constipation
Drug history (NSAID, aspirin, Warfarin)
Smoking
Hx of chronic liver disease
Hx of abdominal surgery

21. A 20- year old female complains of diarrhea
A 20- year old female complains of diarrhea. Take a problem-focused history and give the most likely diagnosis
Is it true diarrhea or something else?
Number of bowel movements
Amount of stool at each bowel movement
Consistency of stools
Blood or mucous with stool
Floating / foul smell/hard to flush
Symptoms occurring even during sleep (nocturnal symptoms)
Nausea/vomiting
Location and character of abdominal pain
Relation of symptoms to food
Loss of appetite
Weight loss
Skin Rash
Mouth ulcers
Eye symptoms
Low back pain or joint pains
Anal pain/discharge
Fever
Night sweats
Family history/social history
Drug history
Diet history
Surgical history

22. Remember! Diarrhea is liquid stools AND large amount of bowel movements AND frequent stools (>3/day)

23. Remember! One complaint at a time Start with an open-ended question
Move from general to specific
Summarize!

24. Good Luck!