medical conditions* hospitalisations serious illnesses / injuries operations *abcde (asthma, bp,...

GI Histories by Tom and Tom

Presenting Complaint

History of presenting complaint

Past Medical History

Drug History

Family History

Social History

Systems Review

Ideas, concerns, expectations

WIPERW – WASH HANDS

I – INTRODUCTION

P – PERMISSION

E – EXPLANATION

R – RIGHT SIDE OF BED

PRESENTING COMPLAINT (PC)

FIND YOURSELF AN OPEN QUESTION AND STICK WITH IT…

“WHY HAVE YOU COME TO SEE US TODAY?”

“CAN YOU TELL ME WHY YOU’RE IN HERE…”

“COULD YOU TELL ME A BIT MORE ABOUT…”

HISTORY OF PRESENTING COMPLAINT

(HPC)

Pain mnemonicS – SITE Q – QUALITY I – INTENSITYT – TIMING A – AGGRAVATING AND RELIEVING FACTORS S – SYMPTOMS ASSOCIATED

QUESTIONS FOR GI“CHANGE IN STOOL?” (FLOAT/ FLUSH, MUCUS, COLOUR, BLOOD , FREQUENCY, ODOR)

“DO YOU FEEL LIKE YOU’RE FINISHED WHEN YOU GO?” (TENESMUS)

“ANY CHANGE IN WEIGHT/APPETITE?”

“ANY HEARTBURN?”

“ANY LUMPS OR BUMPS?”

“VOMITING?”

“ANY DIFFICULTY SWALLOWING?”

Medical conditions*

Hospitalisations

Serious illnesses / injuries

Operations

*ABCDE (ASTHMA, BP, CHOLESTROL, DIABETES, EPILEPSY)

PAST MEDICAL HISTORY (PMH)

Current medications:• Prescribed• Over-the-counter/

Herbal• Recreational drugs

ALLERGIES

DRUG HISTORY (DH)

Anyone in family had similar problem?

What is the health condition of your parents?

Any chronic conditions run in the family? (egs? – cancer, diabetes)

FAMILY HISTORY (FH)

Social History (SH)Work

Home circumstances

• Current smoker?• Past smoker?• How many years?• Cigarettes/ roll-ups / cigars?• How many per day?

Smoking

• Who lives at home – partner? Children? Pets?• Stairs at home?• Need help with housework, shopping, cooking?

• Do you drink alcohol?• What? Wine? Beer?• How much?

Alcohol

Travel• Have you been travelling recently?

• What do you do for a living?• Is your illness affecting your work?

Systems ReviewCouple of questions for each body system e.g:

• Fits, faints, funny turns• Headaches• Vision problems

CNS (central nervous system)

• Shortness of Breath (SOB)• Cough – blood (red flag)

RS (respiratory system)

• Chest pain• “Heart fluttering” (palpitations)• Ankle swelling

CVS (cardiovascular system)

• Change in bowel habits – blood (red flag)• Nausea or vomiting• Weight loss – red flag

GI (gastrointestinal system)

• Change in waterworks• Blood in urine – red flag• Menstrual problems

GU (genitourinary system)

• Joint or muscle pain• Skin rashes• Lumps or bumps – red flag

Other

ICE

IdeasConcernsExpectations

Closing“Is there anything you’d like to add or think I’ve missed?”

“Do you have any questions?”

THANK the patient!!!!!

RED FLAGS

Symptoms that may indicate serious underlying condition

Different for each body system

e.g. coughing-up blood (haemoptysis) and lung cancer

HISTORY TAKING

Signposting“I’d like to ask you about ….”

• Your general health• Your previous health• Your background• etc

WHY?

Patient and examiner know you have a structure

Can I have your number?

Did I see you on Crimewatch?

Are your trousers for sale?

Where do you lunch?

Do you think you’re overreacting?

How long did it take you to grow your beard?

QUESTIONS NOT TO ASK