Gastrointestinal History Taking

If you'd like to support us and get something great in return, check out our PDF OSCE Checklist Booklet containing over 100 OSCE checklists in PDF format.


Gastrointestinal history taking is an important skill that is often assessed in OSCEs. This guide provides a structured approach to taking a gastrointestinal history in an OSCE setting.


Opening the consultation

Wash your hands and don PPE if appropriate.

Introduce yourself to the patient including your name and role.

Confirm the patient’s name and date of birth.

Explain that you’d like to take a history from the patient.

Gain consent to proceed with history taking.

General communication skills

It is important you do not forget the general communication skills which are relevant to all patient encounters. Demonstrating these skills will ensure your consultation remains patient-centred and not checklist-like (just because you’re running through a checklist in your head doesn’t mean this has to be obvious to the patient).

Some general communication skills which apply to all patient consultations include:

  • Demonstrating empathy in response to patient cues: both verbal and non-verbal.
  • Active listening: through body language and your verbal responses to what the patient has said.
  • An appropriate level of eye contact throughout the consultation.
  • Open, relaxed, yet professional body language (e.g. uncrossed legs and arms, leaning slightly forward in the chair).
  • Making sure not to interrupt the patient throughout the consultation.
  • Establishing rapport (e.g. asking the patient how they are and offering them a seat).
  • Signposting: this involves explaining to the patient what you have discussed so far and what you plan to discuss next.
  • Summarising at regular intervals.

Presenting complaint

Use open questioning to explore the patient’s presenting complaint:

  • “What’s brought you in to see me today?”
  • “Tell me about the issues you’ve been experiencing.”

Provide the patient with enough time to answer and avoid interrupting them.

Facilitate the patient to expand on their presenting complaint if required:

  • “Ok, can you tell me more about that?”

Once the patient has finished speaking, it is helpful to check if there are any other issues. If the patient has multiple presenting complaints, work with them to establish a shared agenda for the rest of the consultation:

  • “Ok, so you’ve mentioned that you have three problems today that you’d like addressing. As there may not be time to address them all thoroughly in this consultation, it would be helpful to know which of the issues you feel is most important to deal with today. I’ll then let you know which of these issues I feel is the priority and we can agree on what the focus of today’s consultation should be. Does that sound ok?”
Open vs closed questions

History taking typically involves a combination of open and closed questions. Open questions are effective at the start of consultations, allowing the patient to tell you what has happened in their own words. Closed questions can allow you to explore the symptoms mentioned by the patient in more detail to gain a better understanding of their presentation. Closed questions can also be used to identify relevant risk factors and narrow the differential diagnosis.


History of presenting complaint

Patients with gastrointestinal pathology can present with a wide variety of symptoms including but not limited to nausea, vomiting, abdominal pain, abdominal distension, weight loss and jaundice. The SOCRATES acronym (explained below) is a useful tool that you can use to explore each of the patient’s presenting symptoms.

Key gastrointestinal symptoms

Upper gastrointestinal symptoms include:

  • Jaundice: yellowing of the skin/sclera and dark urine. Causes include hepatitis, liver cirrhosis and biliary obstruction (e.g. gallstone, pancreatic cancer).
  • Aphthous ulceration: round or oval ulcers occurring on the mucous membranes inside the mouth. Aphthous ulcers are typically benign (e.g. due to stress or mechanical trauma), however, they can be associated with iron, B12 and folate deficiency as well as Crohn’s disease.
  • Vomiting: a common symptom of many gastrointestinal disorders including infections (e.g. gastroenteritis), gastro-oesophageal reflux disease (GORD), pyloric stenosis (projectile non-bilious vomiting), bowel obstruction (typically bilious), gastroparesis (e.g. secondary to diabetes), pharyngeal pouch and oesophageal stricture (vomit containing undigested food).
  • Haematemesis: the vomiting of blood which can be fresh red in colour (e.g. Mallory-Weiss tear, oesophageal variceal rupture) or coffee ground in appearance (e.g. gastric or duodenal ulcer).
  • Gastro-oesophageal reflux: backflow of the stomach’s contents into the oesophagus secondary to lower oesophageal sphincter incompetence. Patients typically describe epigastric discomfort which is burning in nature.
  • Dysphagia: difficulty swallowing which may affect solid food, liquids or both depending on its severity (e.g. oesophageal cancer).
  • Odynophagia: pain during swallowing which may be associated with oesophageal obstruction (e.g. stricture) or infection (e.g. oesophageal candidiasis).

Lower gastrointestinal symptoms include:

  • Abdominal pain: may be localised (e.g. right iliac fossa in appendicitis) or generalised (e.g. spontaneous bacterial peritonitis).
  • Abdominal distension: associated with a wide range of gastrointestinal pathology including ascites, constipation, bowel obstruction, organomegaly and malignancy.
  • Constipation: causes include dehydration, reduced bowel motility (e.g. autonomic neuropathy) and medications (e.g. opiates, ondansetron, iron supplements).
  • Diarrhoea: causes include infection (e.g. C.difficle), irritable bowel syndrome, inflammatory bowel disease, medications (e.g. laxatives), constipation (with overflow) and malignancy.
  • Steatorrhoea: the presence of excess fat in faeces causing them to appear pale and be difficult to flush. Causes of steatorrhoea include pancreatitis, pancreatic cancer, biliary obstruction, coeliac disease and medications (e.g. Orlistat).
  • Malaena: dark, tar-like sticky stools containing digested blood secondary to upper gastrointestinal bleeding (e.g. peptic ulcer).
  • Haematochezia: fresh red blood passed per rectum which may be caused by haemorrhoids, anal fissures and lower gastrointestinal malignancy.

Systemic symptoms include:

  • Anorexia
  • Weight loss (e.g. malabsorption, malignancy)
  • Nausea
  • Fatigue
  • Fever (e.g. intrabdominal infection)
  • Pruritis (e.g. cholestasis)
  • Confusion (e.g. hepatic encephalopathy).

SOCRATES

The SOCRATES acronym is a useful tool for exploring each of the patient’s presenting symptoms in more detail. It is most commonly used to explore pain, but it can be applied to most other symptoms, although some of the elements of SOCRATES may not be relevant to all symptoms.

Site

Ask about the location of the symptom:

  • “Where is the pain?”
  • “Can you point to where you experience the pain?”

Onset

Clarify how and when the symptom developed:

  • “Did the pain come on suddenly or gradually?”
  • “When did the pain first start?”
  • “How long have you been experiencing the pain?”

Character

Ask about the specific characteristics of the symptom:

  • “How would you describe the pain?” (e.g. sharp, dull ache)
  • “Is the pain constant or does it come and go?”

Radiation

Ask if the symptom moves anywhere else:

  • “Does the pain spread elsewhere?”

Associated symptoms

Ask if there are other symptoms which are associated with the primary symptom:

  • “Are there any other symptoms that seem associated with the pain?” (e.g. fever in intrabdominal infection, vomiting in bowel obstruction)

Time course

Clarify how the symptom has changed over time:

  • “How has the pain changed over time?”

Exacerbating or relieving factors

Ask if anything makes the symptom worse or better:

  • “Does anything make the pain worse?” (e.g. GORD is worsened by lying flat)
  • “Does anything make the pain better?” (e.g. GORD is improved with antacid medication)

Severity

Assess the severity of the symptom by asking the patient to grade it on a scale of 0-10:

  • “On a scale of 0-10, how severe is the pain, if 0 is no pain and 10 is the worst pain you’ve ever experienced?”

If the symptom is weight loss, try to quantify the amount of weight the patient has lost over a specific time period.

Abdominal pain locations

The location of a patient’s abdominal pain may help to narrow the differential diagnosis:

  • Right iliac fossa pain (appendicitis, Crohn’s disease, ectopic pregnancy)
  • Left iliac fossa (diverticulitis, ectopic pregnancy)
  • Epigastric pain (oesophagitis and gastritis)
  • Right upper quadrant pain (cholecystitis and hepatitis)
  • Flank pain (renal colic and pyelonephritis)
  • Suprapubic pain (urinary tract infection)
Gastrointestinal risk factors

When taking a gastrointestinal history it’s essential that you identify risk factors for gastrointestinal disease as you work through the patient’s history (e.g. past medical history, family history, social history).

Important gastrointestinal risk factors include:

  • Pre-existing gastrointestinal disease (e.g. GORD, Crohn’s disease)
  • Family history of gastrointestinal disease (e.g. familial adenomatous polyposis)
  • Alcohol
  • Smoking
  • Recreational drugs
  • Diet

Ideas, concerns and expectations

A key component of history taking involves exploring a patient’s ideas, concerns and expectations (often referred to as ICE) to gain insight into how a patient currently perceives their situation, what they are worried about and what they expect from the consultation.

The exploration of ideas, concerns and expectations should be fluid throughout the consultation in response to patient cues. This will help ensure your consultation is more natural, patient-centred and not overly formulaic.

It can be challenging to use the ICE structure in a way that sounds natural in your consultation, but we have provided several examples for each of the three areas below.

Ideas

Explore the patient’s ideas about the current issue:

  • “What do you think the problem is?”
  • “What are your thoughts about what is happening?”
  • “It’s clear that you’ve given this a lot of thought and it would be helpful to hear what you think might be going on.”

Concerns

Explore the patient’s current concerns:

  • “Is there anything, in particular, that’s worrying you?”
  • “What’s your number one concern regarding this problem at the moment?”
  • “What’s the worst thing you were thinking it might be?”

Expectations

Ask what the patient hopes to gain from the consultation:

  • “What were you hoping I’d be able to do for you today?”
  • “What would ideally need to happen for you to feel today’s consultation was a success?”
  • “What do you think might be the best plan of action?”

Summarising

Summarise what the patient has told you about their presenting complaint. This allows you to check your understanding of the patient’s history and provides an opportunity for the patient to correct any inaccurate information.

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, in a history taking context, involves explicitly stating what you have discussed so far and what you plan to discuss next. Signposting can be a useful tool when transitioning between different parts of the patient’s history and it provides the patient with time to prepare for what is coming next.

Signposting examples

Explain what you have covered so far: “Ok, so we’ve talked about your symptoms, your concerns and what you’re hoping we achieve today.”

What you plan to cover next: “Next I’d like to quickly screen for any other symptoms and then talk about your past medical history.”


Systemic enquiry

A systemic enquiry involves performing a brief screen for symptoms in other body systems which may or may not be relevant to the primary presenting complaint. A systemic enquiry may also identify symptoms that the patient has forgotten to mention in the presenting complaint.

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

Some examples of symptoms you could screen for in each system include:

  • Systemic: fevers, weight change, fatigue
  • Cardiovascular: chest pain, oedema, syncope, palpitations
  • Respiratory: dyspnoea, cough, sputum, wheeze, haemoptysis, pleuritic chest pain
  • Genitourinary: oliguria, polyuria, dysuria, urinary frequency
  • Neurological: visual changes, motor or sensory disturbances, headache, confusion
  • Musculoskeletal: chest wall pain, trauma
  • Dermatological: rashes, skin lesions, jaundice

Travel history

If the patient’s symptoms are suggestive of an infective aetiology (e.g. infective diarrhoea, hepatitis, malaria) take a thorough travel history:

  • Area of travel: note areas with a high prevalence of specific diseases (e.g. malaria, campylobacter, shigella, giardia).
  • Diet: ask the patient if they recently ate any high-risk food in these areas (e.g. salmonella).
  • Insect bites: ask if the patient noticed any insect bites (e.g. mosquito bites preceding malarial symptoms).
  • Contact with contaminated water: ask the patient if they ingested water which may have been contaminated (e.g. swimming in contaminated water).

Past medical history

Ask if the patient has any medical conditions: 

  • “Do you have any medical conditions?”
  • “Are you currently seeing a doctor or specialist regularly?”

If the patient does have a medical condition, you should gather more details to assess how well controlled the disease is and what treatment(s) the patient is receiving. It is also important to ask about any complications associated with the condition including hospital admissions.

Ask if the patient has previously undergone any surgery or procedures (e.g. bowel resection, endoscopy, colonoscopy):

  • “Have you ever previously undergone any operations or procedures?”
  • “When was the operation/procedure and why was it performed?”
  • “What were the results of the colonoscopy/endoscopy?”

Allergies

Ask if the patient has any allergies and if so, clarify what kind of reaction they had to the substance (e.g. mild rash vs anaphylaxis).

Examples of relevant medical and surgical history

Past medical history relevant to gastrointestinal disease:

  • Endoscopy and colonoscopy dates and results
  • Iron deficiency anaemia
  • B12 deficiency
  • Irritable bowel syndrome
  • Constipation
  • Crohn’s disease
  • Ulcerative colitis
  • Abdominal malignancy
  • Gastroesophageal reflux disease (GORD)
  • Coeliac disease
  • Colonic polyps
  • Diverticular disease
  • Non-alcoholic fatty liver disease
  • Liver cirrhosis
  • Gallstones

Past surgical history relevant to gastrointestinal disease:

  • Abdominal surgery (e.g. cholecystectomy, bowel resection)
  • Previous bowel obstruction
  • Stoma formation

Drug history

Ask if the patient is currently taking any prescribed medications or over-the-counter remedies:

  • “Are you currently taking any prescribed medications or over-the-counter treatments?”

If the patient is taking prescribed or over the counter medications, document the medication name, dose, frequency, form and route.

Ask the patient if they’re currently experiencing any side effects from their medication (e.g. constipation secondary to opiates, jaundice secondary to antibiotics):

  • “Have you noticed any side effects from the medication you currently take?”

Ask the patient (if relevant) if they are using any form of contraception and if there is any chance they could be pregnant (ectopic pregnancy commonly presents with abdominal pain):

  • “Are you currently sexually active?”
  • “Are you using any form of contraception?”
  • “Is there any chance you could be pregnant?”
Commonly prescribed gastrointestinal medications

Medications commonly prescribed to patients with gastrointestinal disease include:

  • Laxatives (e.g. senna, docusate)
  • Loperamide
  • Sodium alginate/calcium carbonate (e.g. Gaviscon)
  • Proton pump inhibitors (e.g. lansoprazole)
  • H2 receptor antagonists (e.g. ranitidine)
  • Hyoscine butylbromide
  • Immunosuppressants (e.g. corticosteroids, ciclosporin, methotrexate, biologics)

Some over the counter drugs which may impact the gastrointestinal system include:

  • Aspirin (may worsen gastrointestinal bleeding)
  • NSAIDs (may cause gastric/duodenal ulceration)
  • St John’s Wort (an enzyme inducer which may alter the clearance of prescribed medications)
Medications with gastrointestinal side effects

Medications with gastrointestinal side effects include:

  • Opiates (constipation, nausea)
  • Penicillin (hepatitis)
  • Ondansetron (constipation)

Family history

Ask the patient if there is any family history of gastrointestinal disease (e.g. bowel cancer, haemochromatosis, inflammatory bowel disease, hereditary nonpolyposis colorectal cancer, familial adenomatous polyposis):

  • “Do any of your parents or siblings have any liver or bowel problems?” 

If one of the patient’s close relatives are deceased, sensitively determine the age at which they died and the cause of death:

  • “I’m really sorry to hear that, do you mind me asking how old your mother was when she died?”
  • “Do you remember what medical condition was felt to have caused her death?”

Social history

Explore the patient’s social history to both understand their social context and identify potential gastrointestinal risk factors.

General social context

Explore the patient’s general social context including:

  • the type of accommodation they currently reside in (e.g. house, bungalow) and if there are any adaptations to assist them (e.g. stairlift)
  • who else the patient lives with and their personal support network
  • what tasks they are able to carry out independently and what they require assistance with (e.g. self-hygiene, housework, food shopping)
  • if they have any carer input (e.g. twice daily carer visits)

Smoking

Record the patient’s smoking history, including the type and amount of tobacco used.

Calculate the number of ‘pack-years‘ the patient has smoked for:

  • pack-years = [number of years smoked] x [average number of packs smoked per day]
  • one pack is equal to 20 cigarettes

Smoking significantly increases the risk of developing gastrointestinal cancers (e.g. oral and oesophageal cancer) and Chrohn’s disease.

See our smoking cessation guide for more details.

Alcohol

Record the frequency, type and volume of alcohol consumed on a weekly basis.

Excess alcohol intake increases the risk of gastrointestinal malignancy (e.g. oesophageal and stomach cancer) and the development of alcoholic hepatitis/cirrhosis.

Offer support services to assist the patient in reducing their alcohol intake.

See our alcohol history taking guide for more information.

Recreational drug use

Ask the patient if they use recreational drugs and if so determine the type of drugs used and their frequency of use. Intravenous drug use is a risk factor for hepatitis.

Gambling

Ask the patient if they gamble and if they feel this is a problem.

Gambling is causative of several decrements to health directly, such as increased sedentary behaviour during the time spent gambling, poor sleep, reduced levels of self-care and anxiety. Patients with a gambling problem are also more likely to have substance misuse issues.1

Problematic gambling can be assessed via the Problem Gambling Severity Index (PGSI).

Diet

Ask what the patient’s diet looks like on an average day and if the patient has noticed any food category that triggers or worsens their symptoms.

A low fibre diet and inadequate fluid intake is a common cause of constipation.

Patients with coeliac disease may report abdominal pain, nausea and diarrhoea when eating gluten-containing foods. Patients with biliary colic may report that fatty foods trigger right upper quadrant pain.

Exercise

Ask if the patient regularly exercises (including frequency and exercise type).

Sexual history

If considering blood-borne viruses such as hepatitis, ask the patient about their sexual history to assess their risk.

See our guide to taking a sexual history for more details.


Closing the consultation

Summarise the key points back to the patient.

Ask the patient if they have any questions or concerns that have not been addressed.

Thank the patient for their time.

Dispose of PPE appropriately and wash your hands.


References

  1. World Health Organisation. The epidemiology and impact of gambling disorder and other gambling-related harm. Published 26-28 June 2017. Available from: [LINK].

 

Print Friendly, PDF & Email