Print Friendly, PDF & Email

Gastrointestinal history taking requires a systematic approach to ensure you don’t miss anything important.  This guide structures the history in parallel with the structure of the GI system, beginning at the mouth and working downwards. Over time you will stop using this approach and only ask a smaller more focused subset of these questions which are relevant to the given presenting complaint, but it takes time to become competent at this, so this is a good starting point. Check out the gastrointestinal OSCE mark scheme here.



Opening the consultation

Introduce yourself – name / role

Confirm patient details – name / DOB

Explain the need to take a history

Gain consent

Ensure the patient is comfortable


Presenting complaint

It’s important to use open questioning to elicit the patient’s presenting complaint

“So what’s brought you in today?”   or  ”Tell me about your symptoms”

Allow the patient time to answer, trying not to interrupt or direct the conversation.

Facilitate the patient to expand on their presenting complaint if required

“Ok, so tell me more about that”  ”Can you explain what that pain was like?”


History of presenting complaint

The following questions should be asked for each symptom the patient is experiencing.

Onset – when did the symptom start? / was the onset acute or gradual?

Duration – minutes / hours / days / weeks / months / years

Severity – e.g. if symptom is weight loss – how much weight loss?

Course – is the symptom worsening, improving, or continuing to fluctuate?

Intermittent or continuous? – is the symptom always present or does it come and go?

Precipitating factors – are there any obvious triggers for the symptom?

Relieving factors – does anything appear to improve the symptoms e.g. increasing dietary intake

Associated features – are there other symptoms that appear associated (e.g. fever/malaise) 

Previous episodes – has the patient experienced this symptom previously?

 

Key gastrointestinal symptoms:

  • Dysphagia / odynophagia  – solids vs liquids 
  • Nausea / vomiting – triggers/ colour of vomit / haematemesis
  • Reduced appetite / weight loss
  • Gastroesophageal reflux
  • Abdominal pain – SOCRATES
  • Abdominal distension
  • Altered bowel habit – constipation / diarrhoea / fresh blood / malaena 
  • Systemic symptoms – jaundice / fever / malaise / fatigue

 

Upper gastrointestinal tract symptoms

Mouth  Pain / Ulcers / Growths

Dysphagia – Onset / Progression / Solids and/or liquids

Odynophagia – pain on swallowing – oesophageal candidiasis

Progressive dysphagia (difficulty swallowing solids at first, then eventually difficulty with liquids) suggests the presence of a malignant stricture. Especially in elderly patients with associated weight loss and iron deficiency anaemia.

Nausea and vomiting

Frequency and volume – high frequency and volume increases risk of dehydration

Projectile vomiting – obstruction

What does the vomit look like? 

  • Undigested food – pharyngeal pouch / achalasia / oesophageal stricture
  • Non-bilious vomit – pyloric obstruction (i.e. pyloric stenosis)
  • Bilious vomit/ faecal matter – lower GI obstruction (i.e. severe constipation)

Haematemesis

Colour:

  • Fresh red blood – undigested – acute bleed – Mallory Weiss tear / oesophageal variceal rupture
  • Coffee ground – digested – bleeding peptic/ duodenal ulcer

Preceded by forceful retching?Mallory Weiss tear

 

Anorexia/weight loss

How much weight over how long? – always suspect malignancy – especially in the elderly

Decreased appetite –  may suggest malignancy, or in younger patients possibly anorexia nervosa

 

Abdominal pain

Is pain localised to a specific area of the abdomen? 

  • Right iliac fossa – appendicitis / Crohn’s disease
  • Left iliac fossa – diverticulitis 
  • Epigastricgastritis/oesophagitis
  • Right upper quadrant – cholecystitis/hepatitis 
  • Flank – pyelonephritis 
  • Suprapubic – cystitis 

 

Is the pain intermittent or continuous?

  • Intermittent – e.g. renal colic/biliary colic/bowel obstruction
  • Continuous – e.g. cystitis/peritonitis

 

Use SOCRATES to gain more details about the pain.

 

Bloating  

Common causes of abdominal distension:

  • Fat – obesity 
  • Flatus – paralytic ileus/obstruction
  • Faeces – constipation
  • Fluid – ascites 
  • Fetus – pregnancy

Altered bowel habit

Diarrhoea

Consistencyhow formed is it? (Bristol stool chart)

Mucous Inflammatory bowel disease (IBD) / Irritable bowel syndrome (IBS)

BloodFresh red blood (anal fissure/haemorrhoids/IBD). Melaena (upper gastrointestinal bleed)

Urgency IBD/IBS/gastroenteritis

Recent antibiotics? C. Difficile 

Recent suspect food? – food poisoning

Laxative use?

 

Constipation

Duration of constipation

Absolute constipation?not passing flatus – obstruction

 

Colour of the stool

Black (Melaena) – peptic ulcer / duodenal ulcer / malignancy

Fresh red blood – anal fissure / haemorrhoids / IBD /  polyp / lower GI malignancy

Pale (steatorrhoea) – biliary obstruction (gallstones / malignancy)

 

Jaundice

Yellowing of the skin and sclera 

Dark urine

 

Causes of jaundice:

  • Infectioushepatitis B and C / malaria
  • Malignancypancreatic cancer / cholangiocarcinoma
  • Alcoholic liver disease
  • Autoimmuneautoimmune hepatitis / primary sclerosing cholangitis
  • CongenitalGilbert’s syndrome (benign)

 

Pain

If pain is a symptom, clarify the details of the pain using SOCRATES

  • Site – where is the pain 
  • Onset – when did it start? / sudden vs gradual?
  • Character – sharp / dull ache / burning
  • Radiation – does the pain move anywhere else? 
  • Associations – other symptoms associated with the pain 
  • Time course – worsening / improving / fluctuating / time of day dependent
  • Exacerbating / Relieving factors – does anything make the pain worse or better?
  • Severity – on a scale of 0-10, how severe is the pain?

Ideas, Concerns and Expectations

Ideas – what are the patient’s thoughts regarding their symptoms?

Concerns – explore any worries the patient may have regarding their symptoms

Expectations – gain an understanding of what the patient is hoping to achieve from the consultation

Summarising

Summarise what the patient has told you about their presenting complaint.

This allows you to check your understanding regarding everything the patient has told you.

It also allows the patient to correct any inaccurate information and expand further on certain aspects.

Once you have summarised, ask the patient if there’s anything else that you’ve overlooked.

Continue to periodically summarise as you move through the rest of the history.

Signposting

Signposting involves explaining to the patient:

  • What you have covered – “Ok, so we’ve talked about your symptoms”
  • What you plan to cover next – “Now I’d like to discuss your past medical history”

Past medical history

Gastrointestinal disease inflammatory bowel disease (IBD) /  irritable bowel syndrome / malignancy / gastroesophageal reflux (GORD)

Other medical conditions

Surgical history – e.g. appendectomy / colectomy /  c-section

Any recent hospital admissions? – when and why? 


Travel history

Local food? – e.g. salmonella poisoning 

Insect bites? – malaria 

Contact with dirty water? – campylobacter / shigella / giardia


Drug history

Gastrointestinal medications:

  • Laxatives
  • Loperamide
  • Proton pump inhibitors
  • H2 receptor antagonists
  • Sodium alginate/calcium carbonate e.g. Gaviscon

 

Regular medications – NSAIDS / Steroids /Bisphosphonates – (Gastroduodenal erosions)

Over the counter drugs – NSAIDS / laxatives

Contraception? – consider gynaecological causes of abdominal pain – ectopic pregnancy / miscarriage

ALLERGIES?


Family history

Gastrointestinal disease – malignancy / IBD / GORD

Hereditary bowel conditionsHNPCC / FAP

Other significant medical conditions


Social history

Smoking – How many cigarettes a day? How many years have they smoked for?

Alcohol – How many units a week? – be specific about type / volume / strength of alcohol

Recreational drug use – IV drug use is a risk factor for hepatitis

Sexual history – important if considering blood-borne viruses – e.g. hepatitis 

 

Diet:

  • Lack of fibre – constipation
  • Gluten – coeliac disease
  • Fatty foods – may be associated with upper abdominal pain – cholecystitis 

 

Living situation:

  • House / flat  – stairs / adaptations
  • Who lives with the patient? – important when considering discharging home from the hospital
  • Any carer input? – what level of care do they receive?

 

Activities of daily living:

  • Is the patient independent and able to fully care for themselves?
  • Can they manage self-hygiene/housework/food shopping?
  • Is the illness interfering with the patient’s ability to do the above?

Occupation 


Systemic enquiry

Systemic enquiry involves performing a brief screen for symptoms in other body systems.

This may pick up on symptoms the patient failed to mention in the presenting complaint.

Some of these symptoms may be relevant to the diagnosis (e.g. erythema nodosum in inflammatory bowel disease).

Choosing which symptoms to ask about depends on the presenting complaint and your level of experience.

 

Cardiovascular – Chest pain / Palpitations  / Dyspnoea /  Syncope / Orthopnoea  / Peripheral oedema 

RespiratoryDyspnoea / Cough / Sputum / Wheeze / Haemoptysis / Chest pain

GI – Appetite / Nausea / Vomiting / Indigestion / Dysphagia / Weight loss / Abdominal pain / Bowel habit 

Urinary –  Volume of urine passed / Frequency / Dysuria  / Urgency / Incontinence

CNS – Vision / Headache / Motor or sensory disturbance/ Loss of consciousness / Confusion

Musculoskeletal – Bone and joint pain / Muscular pain 

Dermatology – Rashes / Skin breaks / Ulcers / Lesions


Closing the consultation

Thank patient

Summarise the history


 

Assessment

0%