2. 1 MBChB – CURRICULUM Clinical Methods Semester 6 Gastroenterology

3. 2 DOCTOR What is IBS? Do I have cancer? I can't lead a normal life I have this pain in my pain in myabdomen Where is the toilet? Can it be treated? Patient’s concerns

4. 3 Psychologicalcomorbidity Seriousdisease Hidden agenda narcotics,laxatives,benefits Shall I refer? Recent stressful event stressful event Impaired daily function Drossman et al, 1995; 1997 Doctor’s concerns

5. 4 History taking A: PRINCIPLE PROBLEM B: SYSTEMIC ENQUERY

6. 5 History taking  ± 80 % of diagnosis can be made by proper history taking  Put patient at ease – patients always afraid of doctors  Acquire patient’s trust

7. 6 A: MAIN COMPLAINT 1. Mouth Mouth 2. Problems with swallowing Problems with swallowing Problems with swallowing 3. Nausea Nausea 4. Vomiting Vomiting 5. Eating habits Eating habits Eating habits 6. Weight Weight 7. Heartburn Heartburn 8. Gaseousness, bloating & flatulence Gaseousness, bloating & flatulence Gaseousness, bloating & flatulence 9. Abdominal pain Abdominal pain Abdominal pain 10. Bowel habits Bowel habits Bowel habits 10.1 Diarrhoea Diarrhoea 10.2 Constipation Constipation 11. Jaundice Jaundice

8. 7 1. Mouth  Mouth sores  Breath  Tongue & taste  Teeth & gums  Throat Back to MAIN COMPLAINT MENU

9. 8 2. Problems with swallowing  Dysphagia – difficulty with swallowing Dysphagia – difficulty with swallowing Dysphagia – difficulty with swallowing  Aphagia – no water or solids can be swallowed (emergency for obstruction)  Odynophagia – painfull swallowing  Globus pharyngeous (hystericus) – lump lodged in the throat feeling  Phagophobia – fear of swallowing  Infections – immune status dysphagia & odynophagia Back to MAIN COMPLAINT MENU

10. 9 2.1 Dyphagia (difficulty with swallowing) Water or solids Water or solids Acute or chronic presentation Acute or chronic presentation Where does food get stuck Where does food get stuck Nasal regurgitation Nasal regurgitation Simultaneous symptoms Simultaneous symptoms  Chest pain, hoarseness, weight loss Hiccup – level of diaphragm Hiccup – level of diaphragm 2. Problems with swallowing Back to problems with Swallowing menu

11. 10 3. Nausea  Nausea in relation with meals  Nausea for specific foods – fatty meals – gall stones  With emotional stress  Time – morning sickness pregnancy pregnancy raised intracranial pressure raised intracranial pressure  Drugs  Fever Back to MAIN COMPLAINT MENU

12. 11 4. Vomiting 4. Vomiting  Vomiting with or without nausea  Projectile vomiting ( raised intracranial pressure )  In relation with meals  With emotional stress  Drugs  Fever  Simultaneous bowel motions – none or Diarrhoea  What does the patient vomit: undigested food undigested food blood (hematemesis or black coffee grounds) blood (hematemesis or black coffee grounds) bile bile Back to MAIN COMPLAINT MENU

13. 12 5. Eating habits  Appetite increase or decreased 6. Weight  Gain or loss  Loss on purpose or spontaneous  Loss gradually or recently Back to MAIN COMPLAINT MENU

14. 13 7. Heartburn  When With or after meals With or after meals Evenings Evenings Whole day Whole day How often How often  Alarm signs dysphagia dysphagia coughing spells especially at night coughing spells especially at night weight loss weight loss Back to MAIN COMPLAINT MENU

15. 14 8. Gaseousness, bloating & flatulence  Aerophagia (swallowing of air)  Belching (vomiting of air) & Flatulence  Abdominal distention Back to MAIN COMPLAINT MENU

16. 15 9. Abdominal pains Associated with:  Meals  Bloating and bowel distention  Specific abdominal area  Cramps / deep pain  Constant or intermittend  Improve with passing of stools Back to MAIN COMPLAINT MENU

17. 16 10. Bowel habits  What is your normal bowel habit  Recent change in bowel habit Back to MAIN COMPLAINT MENU

18. 17 10.1 Diarrhoea  Acute of chronic presentation (>4 weeks)  Volume and frequency Volume and frequency Volume and frequency  Day / night rhythm Day / night rhythm Day / night rhythm  Content Content  Colour, odour, consistency  Tenesmus and pain (anus)  Drugs (antibiotics en laxatives)  Sexual activities (AIDS)  Travelers Diarrhoea  Weight loss Weight loss Weight loss  Previous surgery Previous surgery Previous surgery Back to MAIN COMPLAINT MENU

19. 18 10.1 Diarrhoea  Volume and frequency High volume, low frequency – small bowel High volume, low frequency – small bowel Low volume, high frequency - colon Low volume, high frequency - colon  Day / Night rhythm Only during daytime – irritable bowel Only during daytime – irritable bowel Only at night (early morning) – diabetic autonomic neuropathy Only at night (early morning) – diabetic autonomic neuropathy Back to diarrhoea Main menu

20. 19 10.1 Diarrhoea  Content water water mucus mucus blood (hematochezia or black melena) blood (hematochezia or black melena) Food residue (undigested) Food residue (undigested) Float on water (fat malabsorption) Float on water (fat malabsorption) Back to diarrhoea Main menu

21. 20 10.1 Diarrhoea  Weight loss diabetes mellitus diabetes mellitus malignancy malignancy psychiatric psychiatric hyperthyroidism hyperthyroidism malabsorption malabsorption TB TB AIDS AIDS Back to diarrhoea Main menu

22. 21 10.1 Diarrhoea  Previous surgery subtotal gastrectomy subtotal gastrectomy short bowel syndrome short bowel syndrome afferent loop syndrome afferent loop syndrome Ileum-resection Ileum-resection post cholecystectomy syndrome (bile acids) post cholecystectomy syndrome (bile acids) Back to diarrhoea Main menu

23. 22 10.2 Constipation  Individual variation according to eating habits  Acute or chronic presentation  Frequency – how many times per week  Abdominal distention  Pain – improvement after passing of stools  Bloating and flatulence  Consistency – hard pellet stools  Straining (25 %)

24. 23 10.2 Constipation (continue)  Feeling of incomplete evacuation  Blood per rectum – after, around or in the stools – red (hematochazea) or black melena stools  Drugs  Emosional status  Weight loss  Previous surgery  Other diseases – Diabetes Mellitus, Hypothyroidism Back to MAIN COMPLAINT MENU

25. 24 11. Jaundice  Family history – Hepatitis B  Occupation – doctors and laboratory personnel  Transfusions and injections – Hepatitis B en C  Tattoos and skin rings  Alcohol use  Travel history – Hepatitis  Operations  Sexual orientation – Hepatitis B en C  Medication B: Systemic enquiry

26. 25 History taking A: MAIN COMPLAINT B: SYSTEMIC ENQUERY

27. 26 B: SYSTEMIC ENQUERY 1. All other systems 2. Previous diseases 3. Previous operations 4. Current medication 5. Occupations 6. Socio-economic and habits

28. 27