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Gastroenterology History Taking and Differential Diagnoses

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History of Presenting Complaint

All symptoms

With each presenting complaint, explode the symptom:

  • When did it start?
  • How long has this been going on?
  • Did it come on suddenly or gradually?
  • Is it continuous or intermittent?
  • Has this ever happened before?

Abdominal pain

Use SOCRATES (site, onset, character, radiation, associated symptoms, timeline, exacerbating or relieving factors, and scale) to assess pain. Specific characteristics of abdominal pain are discussed in Acute Abdominal Pain.

Dysphagia

Questions to consider asking are:

  • Does food get stuck on the way down?
  • Does it feel like there’s any blockage?
  • Is there any pain?
  • Can they point to where they feel any blockage is?
  • Do they regurgitate any food?
  • Do they choke on their food?

Bowel habits

Questions to consider asking are:

  • Have there been any changes to bowel habits?
  • Patients may describe ‘constipation’ or ‘diarrhoea’, ask them what this specifically means:
    • How much?
    • How often?
    • What is the consistency of their stool?
    • Is there any urgency?
    • Is there any faecal incontinence?
    • Is passing stool painful?
    • Is there tenesmus?
  • Do they pass any blood?
  • Do they pass any mucus?
  • What is their stool like?
    • Is it black and tarry? – suggests melaena which may be seen in upper gastrointestinal (GI) bleeds
    • Does it float and is it difficult to flush away? – suggests malabsorption of fat

Review of Systems

Red flags

  • Has there been any unexplained weight loss? – may suggest malignancy or malabsorption
  • Has there been any haematemesis – suggests an upper GI bleed
  • Have they coughed up any blood? – suggests an upper GI bleed
    • It might be helpful to ask if it appears as ‘coffee grounds’

Gastrointestinal system

  • How is their appetite? Has it changed?
  • Is there any nausea or vomiting?
  • Has there been any weight loss?
    • Is it unexplained – this is a red flag
  • Have they noticed any yellowing of the skin?
  • Have they noticed any mouth ulcers?
  • Have they had any epigastric burning? – suggests gastro-oesophageal reflux
  • Are they experiencing any itchiness? – this can occur with cholestasis

Systemic features

Gynaecological system

In women of childbearing age, it is important to consider a brief obstetric and gynaecological history if appropriate:

  • The ‘four Ps’ can help:
    • PV bleeding?
      • Any unusual PV bleeding (e.g. intermenstrual, postcoital etc.)
  • PV discharge?
    • Any unusual PV discharge?
  • Pelvic pain?
    • Use SOCRATES
  • Pregnancy?
    • Are they pregnant?
    • When was their last menstrual period?
    • Any previous gynaecological surgery?
    • Any previous ectopic pregnancies?
  • Do they use any hormonal contraceptives?

Other features

  • Have they noticed any skin changes or rashes?
  • Have they had any changes with passing urine?

Travel History

If features point towards an infective cause, it may be helpful to ask:

  • Have they travelled anywhere recently?
    • Where did they go?
  • What did they do when they were abroad?
    • Did they eat anything high-risk (e.g. street food)?
  • Were they bitten by anything?
  • Did they injure themselves?
  • Did they come into contact with unclean water?
  • If appropriate, consider asking about other high-risk activities (e.g. tattoos, piercings, or unprotective sexual intercourse)

Past Medical History

  • Do they have any other medical conditions?
  • Have they ever had any surgery?

Drug History

  • Do they take any regular medication?
  • Do they take any over-the-counter medications or herbal remedies?

Family History

  • Is there any family history of illness?

Allergies

  • Are they allergic to anything?
    • What happens during the allergic reaction?

Social History

  • Do they smoke?
    • How much?
    • How long?
  • Do they drink?
    • How much?
    • How long?
  • Is there any illicit drug use?
    • How much?
    • How long?
  • What do they do for a living?
    • How is this impacted?

Ideas, Concerns, and Expectations

  • Ideas:
    • Do you know what might be going on?
  • Concerns:
    • Is there anything worrying you?
  • Expectations:
    • What are you hoping to get out of this consultation?
  • Summarise and remember to thank the patient

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