Gastrointestinal History

last authored: Sept 2009, David LaPierre

 

The abdominal history and physical exam is important to assess gastrointestinal concerns, but can also help identify problems with the heart, aorta, spine, kidneys, pelvis, and peritoneal cavity.

 

Common gastrointestinal concerns include abdominal pain, dyspepsia, nausea and vomiting, diarrhea, loss of appetite or weight, dysphagia, changes in bowel function, and jaundice. Each should be evaluated specificially if identified.

 

  • history
  • physical exam
  • additional resources

History

 

Chief Concern

A good spot to begin is with "how's your appetite?"

 

 

 

Appetite and Consumption

Ask about diet, referring to Canada's Food Guide.

Ask about dysphagia or odynophagia.

 

Bowel Function and Habit

Start with open-ended questions such as "how are your bowel movements?" "how frequent are they?" have you noticed any changes?"

Nocturnal defecation and urgency are important and should be specifically questioned.

 

Abdominal Pain

Abodominal pain should be described in patient's own words, rated, localized, and described according to timing and aggrevating/relieving factors.

 

Weight Loss

The history is tremendously important when weight loss is occurring. Intake, absorption, and metabolism should all be queried.

 

 

 

 

 

Past Medical History

Previous surgeries should be discussed, as recurrence or complications are possible.

 

Family History

Directly inherited and polygenic disorders are important. Country of origin can also be helpful.

 

 

Social History

Smoking, alcohol, and employment can all be involved in GI disease.

Understanding hopes and expectations, the home situation, and social supports will help with planning the future.

 

Medications

Many drugs affect the GI tract, and drugs taken over the past several months should be identified. NSAIDs can cause hemorrhage, antibiotics can disrupt normal flora, andvarious drugs can cause liver toxicity.

 

Review of Systems

It is quicker to run through all systems the first time a patient is interviewed rather than spend much time on fruitless investigations and find important information later.

 

 

 

Additional Resources

abdominal exam video (St George's University Clinical Skills Online)