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HISTORY TAKING FOR G.I.T. (SUMMARY) BY DR WAQAR MBBS, MRCP ASSISTANT PROFESSOR

Common GIT Presenting complaints * dyspepsia * heartburn *abdominal pain * Bloating/gas * Nausea/vomit. * Hematemesis * melena * Wt loss * Diarrhea/constip. * Weakness * Jaundice * dysphagia

2) H/O presenting c/o : Ask the details 2) H/O presenting c/o : Ask the details. First ask the duration of all symptoms Dysphagia : * for solids or liquids? * Getting worse? * Wt loss? * Pain or just difficulty? ( dysphagia first for solids then liquids esophageal cancer. Dysphagia for solids & liquids from the start motility disorders of esophagus like achalasia. Heartburn : * more supine? What worsens ? Abdominal pain: * All the usual questions of pain * relation to meals ( PUD, IBS, gallstones, pancreatitis) * Relieved by defecation or vomiting?

d) Bloating/gas :. Related to any specific food d) Bloating/gas : * Related to any specific food? *Any recent change in diet habits * Recent travel? * Any chronic constipation? (constipation often causes gas feeling) e) Vomiting : * frequency * projectile or just regurgitation? * Aggravating/relieving factors f) Hematemesis: * color( bright red, dark) * Use of NSAIDs or warfarin? * Is there any epigastric pain? ( ulcer disease) *Any past history of liver disease? (variceal bleeding) g) Melena : * Color ( dark, bright red). Fresh blood indicates lower GI bleed( hemorrhoids, proctitis, colitis) * Relation to stools * Any pain?

h) Diarrhea/Constip. :. frequency h) Diarrhea/Constip. : *frequency * stool consistency ( watery, hard or semi) * Any worms in stool? * Easy to flush? or floating? ( in malabsorption not easy to flush) * Relation to eating?( in IBS, often passing stools after eating) * Recent restaurant visit? * Any recent or past travel? (traveller’s diarrhea caused by E.Coli) * Other people affected? (food poisoning) *related to any specific food? (milk lactose intolerance, wheat celiac disease) * Detailed drug history

Jaundice : * Duration * Fluctuating( Gilbert syndrome) or persistent? * Eating habits? ( restaurant or home). Restau- -rants chances of Hep A * Travel history ( hep A from unclean food & water) * Hist. of blood transfusion? ( Hep B, C) * Wt. loss, abd. pain? ( Pancreas cancer, hepa- -titis).

Jaundice (contd) History of i.v. drugs? ( hep B & C) Any past hepatitis? H/O any hemolytic anemia? Fam. History of jaundice/liver disease Any hepatitis in the spouse ( husband/wife) Any itching alongwith jaundice? ( obstructive jaundice eg. Common bile duct stone, carcinoma of head of pancreas) * Alcohol use?

3) Past history 4) Medical/Surgical history 5) Personal/ Social hist 3) Past history 4) Medical/Surgical history 5) Personal/ Social hist.( iv drugs, addictions, travel, anxiety IBS). Very imp in liver dis. 6) Allergies/Medicines/Occupation 7) Family history ( malabsorption, liver dis.) 8) Drugs ( can cause PUD, Jaundice, Gas, diarrhea etc)

If the history suggests a diagnosis, ask specific questions about that disease

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