HISTORY TAKING GIT
Dr. SOFI MD; FRCP (London);
FRCPEdin; FRCSEdin
DIFFICULTY IN SWALLOWING
&
NAUSEA AND VOMITING
History of Presenting Complaint
• Mouth– Pain, Ulcers,
Growths?
• DysphagiaOnset, Progression, Solids and
/or liquids
• Odynophagia – pain on
swallowing – oesophageal
candidiasis
• Progressive dysphagia, i.e.
difficulty with solids at first,
then with liquids, suggests the
presence of a malignant
stricture. Especially in elderly
patients with associated
weight loss & iron deficiency
anemia.
Nausea & Vomiting
• Frequency & Volume – patient may
be dehydrated & have electrolyte
disturbances
• Projectile? – 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)
• Time of day – Related to meals?
Related to lying down in
bed? (GERD)
Target questions
Has there been a gradual problem with
When taking a history of dysphagia
(difficulty swallowing) ask the patient:
solids or liquids? How is your appetite?
• What have you found most difficult to
Have you lost any weight? Do you smoke?
swallow? Solids or liquids, or both?
Drink alcohol? Oesophageal malignancy
• Where does the food stick?
Do you find your swallowing problems
• When did you first notice this?
come only every so often? Do you suffer
• Did it come on suddenly one day or has
it been a gradual process?
from heartburn? Do you have problems
• When does it happen?
drinking hot drinks? Gastro-oesophageal
• Do you find it is painful to swallow?
reflux disease (GERD)
(odynophagia)
Do you find your swallowing gets worse
• Has food ever gone down the wrong
way?
over the course of the day and towards the
• Do you have a cough or feel short of
end of the meal? Do you become more
breath?
physically tired and weak over the course of
Target questions
the day? Myasthenia gravis
Does it happen only intermittently?
Oesophageal spasm
Do you find the skin over your fingers and
Do you gurgle when drinking? Pharyngeal lips is tight? Do your fingers get cold,
pouch Are you on iron tablets? Plummer –
painful and change colour? Systemic
Vinson syndrome
sclerosis
Dysphagia
HEMATAMESIS
Hematemesis
When taking a history of
hematemesis (blood in vomit),
ask the patient:
• When did it start?
• Was this of sudden onset or
have there been previous smaller
episodes?
• How much blood did you
vomit?
• Is it fresh blood or clotted
blood? Does it look like coffee
grounds?
Target questions
Were you retching or vomiting
before the blood? Mallory – Weiss
tear
Do you have pain in your upper
abdomen? Do you have any past
history of indigestion or ulcer
disease? Ulcer bleed
Are you on painkillers or bloodthinning drugs? Gastritis from
NSAIDs, aspirin, warfarin
Do you drink alcohol and how
much? Have you any liver
problems? Variceal bleed
Have you noticed any weight loss or
decreased appetite? Any problems
swallowing? Upper GI cancer
Is the stool black in colour? Melena
PAIN ABDOMEN/BLOATING
&
ALTERED BOWEL HABITS
Abdominal Pain
Pain – if pain is a symptom, clarify the
details of the pain using SOCRATES
Site – where exactly is the pain / where
is the pain worst
Onset – when did it start? / did it come
on suddenly or gradually?
Character – what does it feel like?
(sharp stabbing / dull ache / burning?)
Radiation – does the pain move
anywhere else? (e.g. chest pain with
left arm radiation)
Associations – any other symptoms
associated with the pain (e.g. chest
pain with SOB)
Time course – does the pain have a
pattern (e.g. worse in the mornings)
Exacerbating / Relieving factors –
anything make it particularly worse or
better?
Severity – on a scale of 0-10, with 0
being no pain & 10 being
the worst pain you’ve ever felt
Is pain localised to specific area of ab
domen?
• RIF – appendicitis, crohn’s disease
• LIF – diverticulitis
• Epigastric – peptic ulcer disease,
gastritis
Indigestion / Heartburn – suggestive
of GERD / gastric ulcer
Bloating (5F’s)
• Fat – obesity
• Flatus – paralytic ileus,
obstruction
• Faeces – constipation
• Fluid – ascites
• Foetus – pregnancy
Altered Bowel Habit
Diarrhoea
Onset – sudden onset
(gastroenteritis, IBD)
Consistency – how formed is it?
(Bristol stool chart)
Blood – Fresh red blood (anal
fissure, haemorrhoids). Melaena
(UGI bleed, malignancy)
Mucous – IBS, IBD
Urgency– IBD, IBS, Gastroenteritis
Incontinence – Cauda equina /
Rectal malignancy
Recent Antibiotics? – C. Difficile
Constipation –
Onset/Timing/Straining/Bleeding
Colour of stool:
• Melaena (Upper GI) – PUD /
duodenal ulcer / malignancy
• Fresh Blood (colon,rectum,
superficial) – anal fissure /
haemorrhoids / rectal tumour
• Pale (Steatorrhoea) – Biliary
obstruction (gallstones /
malignancy)
Diarrhoea
When taking a history of diarrhea, ask
the patient:
• How long have you had it for? Longer
than 2 weeks?
• When was the last formed stool that
you passed?
• What is the consistency of the stool?
• How often do you pass stool? How
much stool do you pass?
• Have you noticed any blood in your
stool?
• Do you get this regularly?
• Have you been previously
investigated for this?
Target questions
Do you have blood in your diarrhea?
Do you have abdominal pain? Do you
have mouth ulcers? Do you have a
family history of inflammatory bowel
disease? Inflammatory bowel disease
Have you lost weight? Have you had
any loss of appetite? Do you have
alternating constipation and
diarrhoea? Do you have the feeling of
not completely emptying your
bowels? Have you had it for more
than 2 weeks? Colonic carcinoma
Do you find your stool floats and has
a greasy appearance? Malabsorption,
e.g. pancreatic insufficiency/coeliac
disease
Do certain foods seem to cause the
diarrhea more than others? Coeliac
disease Have you recently taken
antibiotics? Antibiotic induced
Are you on laxatives? Laxative abuse
Are you diabetic? Autonomic
neuropathy
Have you any thyroid problems? Do
you feel hot and shaky? Do you find
your appetite increased?
Thyrotoxicosis
JAUNDICE
Jaundice
When taking a history of jaundice, ask
the patient:
• When did you first notice the yellow
tinge to your skin and eyes?
• Have you ever had this before?
Target questions Have you any family
history of jaundice? What medications
have you been taking? Prehepatic, e.g.
Gilbert’s syndrome
How much alcohol do you drink? What
medications are you on? Have you had
any recent blood transfusions? Where
have you travelled recently? Have you
had unprotected sex recently? Do you
inject intravenous drugs? Have you
eaten any shellfish? Do you have any
tattoos? Have you been in contact with
someone with jaundice? Hepatic, e.g.
viruses
Have you noticed any change in the
colour of your urine or stool? Are you
itchy? Do you feel bloated? Do you have
any abdominal pain? Have you any
history of gallstones? Have you had any
weight loss or loss of appetite?
Posthepatic, e.g. cholangiocarcinoma,
pancreatic carcinoma
PEPTIC ULCER
PEPTIC ULCERATION
Symptoms
• Epigastric pain:
• – Duodenal ulcer- occurs before
eating & is relieved by eating
– Gastric ulcer – occurs after
eating & is worsened by eating
•
•
•
•
•
Nausea
Oral flatulence
Vomiting
Weight loss
Symptoms relieved by
antacids – non-specific
• Haematemesis
• Melaena
Signs
• Often very few signs in
uncomplicated cases
• Epigastric tenderness
Differential Diagnosis
• Ulcer
Gastric Malignancy
GERD
Gallstones
Chronic pancreatitis
Red Flags
• GI Bleeding
• Dysphagia
• Unintentional weight loss
• Abdominal swelling
• Persistent vomiting
CROHN’S DISEASE
Symptoms
• Abdominal pain
• Diarrhoea – may or may not be
bloody
• Weight loss
• Fever
• Malaise
• Nausea & Vomiting – can occur
due to strictures / bowel
obstruction
• Perianal Discomfort – itching, pain
– due to fistulas / abscesses
• Aptheous ulcers
Signs
• Abdominal tenderness
• Abdominal masses – most commonly right
iliac fossa (terminal ileum)
• Perianal abscesses / skin tags
• Fistula’s
• Rectal strictures – may be noted on PR
Extra-intestinal Features of Crohn’s
• Finger clubbing
• Episcleritis / Uveitis – inflammation of the
episclera or uvea
• Seronegative Spondylarthropathy –
inflammation of axial skeleton – Rh factor -ve
• Erythema Nodosum – red tender nodules
which are usually located over the shins
• Pyoderma Gangrenosum – necrotic deep
ulcers, often on the legs
• Deep Vein Thrombosis
• Autoimmune haemolytic anaemia – antibody
mediated lysis of RBC’s
Inspection
Quadrants of the Abdomen
Topical Anatomy of the Abdomen
Various Causes of Abdominal Distension
Obese abdomen
Ascites
Hepatomegaly
Markedly enlarged gall bladder
Palpation of liver
• With patient supine, place right hand on patient's abdomen, just
lateral to the rectus abdominis
• Ask patient to take a deep breath and try to feel the liver edge as it
descends.
• Be sure to allow liver to pass under the fingers of your right hand,
note texture. Pressing too hard may interfere.
Abdominal Palpation
Hooking Edge of the Liver
Percussion of liver
Technique
1. Starting in the
midclavicular line at
about the 3rd intercostal
space, lightly percuss and
move down.
2. Percuss inferiorly until
dullness denotes the
liver's upper border
(usually at 5th intercostal
space in MCL).
3. Resume percussion from
below the umbilicus on
the midclavicular line in
an area of tympany.
4. Percuss superiorly until
dullness indicates the
liver's inferior border.
5. Measure span in
centimeters.
Abdominal Percussion
Palpation of spleen
• Start in the right lower quadrant and proceed diagonally toward the left upper quadrant.
• Attempt to feel spleen with superficial palpation technique
• With each step, ask the patient to take a deep breath.
• Feel for the tip of the spleen.
Bimanual palpation
Stand on the patient's right side and with your left hand, pull the patient's rib cage anteriorly
and palpate for the tip of the spleen (if enlarged) with your right hand as the patient takes a
deep breath.
Palpation of Kidney
The ballottement method
is normally used.
• Keep your anterior hand
steady in the deep
palpation position in the
right upper quadrant
lateral and parallel to
rectus muscle.
• Attempt to ballot the
kidney with the other
hand in costophrenic
angle.
• An enlarged kidney
should be palpable by
the anterior hand.
• Repeat the same
maneuver for the left
kidney.
Normal:
In an adult, the kidneys are not usually palpable, except
occasionally for the inferior pole of the right kidney. The
left kidney is rarely palpable. An easily palpable or tender
kidney is abnormal. However, the right kidney is frequently
palpable in very thin patients and children.
Auscultation
1. Are bowel
sounds present?
2. If present, are
they frequent or
sparse (i.e.
quantity)?
3. What is the
nature of the
sounds (i.e.
quality)?
Abdominal Auscultation
Assessing for a fluid thrill