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.
Use open questioning to explore the patient’s presentingcomplaint:
“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 presentingcomplaint 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 closedquestions. 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
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).
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).
Haematochezia: fresh red blood passed per rectum which may be caused by haemorrhoids, anal fissures and lower gastrointestinal malignancy.
Weight loss (e.g. malabsorption, malignancy)
Fever (e.g. intrabdominal infection)
Pruritis (e.g. cholestasis)
Confusion (e.g. hepatic encephalopathy).
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.
Ask about the location of the symptom:
“Where is the pain?”
“Can you point to where you experience the pain?”
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?”
Ask about the specificcharacteristics of the symptom:
“How would you describe the pain?” (e.g. sharp, dull ache)
“Is the pain constant or does it come and go?”
Ask if the symptom movesanywhere else:
“Does the pain spread elsewhere?”
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)
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)
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 weightloss, try to quantify the amount of weight the patient has lost over a specifictimeperiod.
Abdominal pain locations
The location of a patient’s abdominalpain may help to narrow the differentialdiagnosis:
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 riskfactors for gastrointestinaldisease as you work through the patient’s history (e.g. past medical history, family history, social history).
Family history of gastrointestinal disease (e.g. familial adenomatous polyposis)
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.
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.”
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?”
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?”
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, 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.
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.”
A systemicenquiry 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:
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
If the patient’s symptoms are suggestive of an infectiveaetiology (e.g. infective diarrhoea, hepatitis, malaria) take a thorough travel history:
Area oftravel: 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 medicalconditions:
“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 howwellcontrolled 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 hospitaladmissions.
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?”
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 gastrointestinaldisease:
Endoscopy and colonoscopy dates and results
Iron deficiency anaemia
Irritable bowel syndrome
Gastroesophageal reflux disease (GORD)
Non-alcoholic fatty liver disease
Past surgical history relevant to gastrointestinaldisease:
Abdominal surgery (e.g. cholecystectomy, bowel resection)
Previous bowel obstruction
Ask if the patient is currently taking any prescribedmedications or over-the-counterremedies:
“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 medicationname, dose, frequency, form and route.
Ask the patient if they’re currently experiencing any sideeffects 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:
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)
Ask the patient if there is any familyhistory 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?”
Explore the patient’s socialhistory to both understand their socialcontext 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)
Record the patient’s smokinghistory, 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 gastrointestinalcancers (e.g. oral and oesophageal cancer) and Chrohn’sdisease.
Ask the patient if they use recreationaldrugs and if so determine the type of drugs used and their frequency of use. Intravenous drug use is a risk factor for hepatitis.
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
Ask what the patient’s diet looks like on an averageday 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.
Ask if the patient regularly exercises (including frequency and exercise type).
If considering blood-borne viruses such as hepatitis, ask the patient about their sexual history to assess their risk.