11/13/24, 8\:10 PM Guide | Gastrointestinalhistory

Gastrointestinalhistory

Table of contents

Opening the consultation

Wash your hands and don PPE if appropriate.
Introduce yourself to the patient, including your name and role.
Con
Explain that you'd like to take a history from the patient.
Gain consent to proceed with history taking.
General communication skills
It is important you do not forget the general communication skills which are relevant to all patient encounters.
Demonstrating these skills will ensure your consultation remains patient-centred and not checklist-like (just because
you're running through a checklist in your head doesn't mean this has to be obvious to the patient).
Some general communication skills which apply to all patient consultations include\:
Demonstrating empathy in response to patient cues\: both verbal and non-verbal.
Active listening\: through body language and your verbal responses to what the patient has said.
An appropriate level of eye contact throughout the consultation.
Open, relaxed, yet professional body language (e.g. uncrossed legs and arms, leaning slightly forward in the chair).
Making sure not to interrupt the patient throughout the consultation.
Establishing rapport (e.g. asking the patient how they are and o
Signposting\: this involves explaining to the patient what you have discussed so far and what you plan to discuss next.
Summarising at regular intervals.

Presenting complaint

Use open questioning to explore the patient’s presenting complaint\:
" W h a t’ s b r o u g h t y o u i n t o s e e m e t o d a y ?"
" T e l l m e a b o u t t h e i s s u e s y o u’ v e b e e n e x p e r i e n c i n g .
"
Provide the patient with enough time to answer and avoid interrupting them.
Facilitate the patient to expand on their presenting complaint if required\:
" O k , c a n y o u t e l l m e m o r e a b o u t t h a t ?"
Once the patient has
complaints, work with them to establish a shared agenda for the rest of the consultation\:
" O k , s o y o u’ v e m e n t i o n e d t h a t y o u h a v e t h r e e p r o b l e m s t o d a y t h a t y o u’ d l i k e a d d r e s s i n g. A s t h e r e m a y n o t b e t i m e t o a d d r e s s
t h e m a l l t h o r o u g h l y i n t h i s c o n s u l t a t i o n , i t w o u l d b e h e l p f u l t o k n o w w h i c h o f t h e i s s u e s y o u f e e l i s m o s t i m p o r t a n t t o d e a l
w i t h t o d a y . I’ l l t h e n l e t y o u k n o w w h i c h o f t h e s e i s s u e s I f e e l i s t h e p r i o r i t y a n d w e c a n a gr e e o n w h a t t h e f o c u s o f t o d a y’ s
c o n s u l t a t i o n s h o u l d b e . D o e s t h a t s o u n d o k ?"
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Open vs closed questions
History taking typically involves a combination of open and closed questions. Open questions are e
consultations, allowing the patient to tell you what has happened in their own words. Closed questions can allow you to
explore the symptoms mentioned by the patient in more detail to gain a better understanding of their presentation.
Closed questions can also be used to identify relevant risk factors and narrow the di

History of presenting complaint

Patients with gastrointestinal pathology can present with a wide variety of symptoms, including but not limited to nausea,
vomiting, abdominal pain, abdominal distension, weight loss and jaundice. The SOCRATES acronym (explained below) is a
useful tool that you can use to explore each of the patient's presenting symptoms.
It is important to be aware that not all ‘gastrointestinal’ symptoms are caused by gastroenterological conditions. For example,
nausea and vomiting may be due to diabetic ketoacidosis or hypercalcaemia, whilst abdominal pain may be due to an
abdominal aortic aneurysm, ectopic pregnancy or testicular torsion, and abdominal bloating may be caused by ovarian cancer.
Key gastrointestinal symptoms
Vomiting is a common symptom of many gastrointestinal disorders, including infections (e.g. gastroenteritis), gastro-
oesophageal repyloric stenosis (projectile non-bilious vomiting), bowel obstruction (typically bilious),
gastroparesis (e.g. secondary to diabetes), pharyngeal pouch and oesophageal stricture (vomit containing undigested
food).
Abdominal pain may be localised (e.g. right iliac fossa in appendicitis) or generalised (e.g. spontaneous bacterial
peritonitis). The diappendicitis, bowel
obstruction, bowel perforation) or has a more chronic course (e.g. in, coeliac disease).
Speci
Jaundice\: yellowing of the skin/sclera and dark urine. Causes include hepatitis, liver cirrhosis and biliary obstruction
(e.g. gallstones, pancreatic cancer).
Haematemesis\: the vomiting of blood which can be fresh red in colour (e.g. Mallory-Weiss tear, oesophageal variceal
rupture) or co
Gastro-oesophageal re
sphincter incompetence. Patients typically describe epigastric discomfort which is burning in nature.
Dysphagia\: di
oesophageal cancer).
Odynophagia\: pain during swallowing, which may be associated with oesophageal obstruction (e.g. stricture) or
infection (e.g. oesophageal candidiasis).
Speci
Abdominal distension\: associated with a wide range of gastrointestinal pathology, including ascites, constipation,
bowel obstruction, organomegaly and malignancy (including ovarian cancer).
Constipation\: causes include dehydration, reduced bowel motility (e.g. autonomic neuropathy) and medications (e.g.
opiates, ondansetron, iron supplements). It can also be a sign of bowel obstruction, particularly if there is 'absolute'
constipation with no passage of stool or
Diarrhoea\: causes include infection (e.g. C. Di
medications (e.g. laxatives), constipation (with over
Steatorrhoea\: the presence of excess fat in faeces, causing them to appear pale and be di
steatorrhoea include pancreatitis, pancreatic cancer, biliary obstruction, coeliac disease and medications (e.g. Orlistat).
Malaena\: dark, tar-like sticky stools containing digested blood secondary to upper gastrointestinal bleeding (e.g.
peptic ulcer).
Haematochezia\: fresh red blood passed per rectum, which may be caused by haemorrhoids, anal and lower
gastrointestinal malignancy.
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Other systemic symptoms include\:
Aphthous ulceration\: round or oval ulcers on the mucous membranes inside the mouth. While aphthous ulcers are
typically benign (e.g., due to stress or mechanical trauma), they can be associated with iron, B12, and folate de
as well as Crohn’s disease.
Anorexia
Weight loss (e.g. malabsorption, malignancy)
Nausea
Fatigue
Fever (e.g. intrabdominal infection)
Pruritis (e.g. cholestasis)
Confusion (e.g. hepatic encephalopathy)

SOCRATES

The SOCRATES acronym is a useful tool for exploring each of the patient's presenting symptoms in more detail. It is most
commonly used to explore pain, but it can be applied to most other symptoms, although some of the elements of SOCRATES
may not be relevant to all symptoms.
Site
Ask about the location of the symptom\:
" W h e r e i s t h e p a i n ?"
" C a n y o u p o i n t t o w h e r e y o u e x p e r i e n c e t h e p a i n ?"
Onset
Clarify how and when the symptom developed\:
" D i d t h e p a i n c o m e o n s u d d e n l y o r g r a d u a l l y ?"
" W h e n d i d t h e p a i n
" H o w l o n g h a v e y o u b e e n e x p e r i e n c i n g t h e p a i n ?"
Character
Ask about the speci
" H o w w o u l d y o u d e s c r i b e t h e p a i n ?" (e.g. sharp, dull ache)
" I s t h e p a i n c o n s t a n t o r d o e s i t c o m e a n d go ?"
Radiation
Ask if the symptom moves anywhere else\:
" D o e s t h e p a i n s p r e a d e l s e w h e r e ?"
Associated symptoms
Ask if there are other symptoms which are associated with the primary symptom\:
" A r e t h e r e a n y o t h e r s y m p t o m s t h a t s e e m a s s o c i a t e d w i t h t h e p a i n ?" (e.g. fever in intrabdominal infection, vomiting in bowel
obstruction)
Time course
Clarify how the symptom has changed over time\:
" H o w h a s t h e p a i n c h a n g e d o v e r t i m e ?"
Exacerbating or relieving factors
Ask if anything makes the symptom worse or better\:
" D o e s a n y t h i n g m a k e t h e p a i n w o r s e ?" (e.g. GORD is worsened by lying
" D o e s a n y t h i n g m a k e t h e p a i n b e t t e r ?" (e.g. GORD is improved with antacid medication)
Severity
Assess the severity of the symptom by asking the patient to grade it on a scale of 0-10\:
" O n a s c a l e o f 0-1 0 , h o w s e v e r e i s t h e p a i n , i f 0 i s n o p a i n a n d 1 0 i s t h e w o r s t p a i n y o u’ v e e v e r e x p e r i e n c e d ?"
If the symptom is weight loss, try to quantify the amount of weight the patient has lost over a speci
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Abdominal pain locations
The location of a patient’s abdominal pain can indicate the underlying cause\:
Epigastric pain\: oesophagitis, gastritis, myocardial infarction, peptic ulcer, pancreatitis
Right upper quadrant pain\: cholecystitis, cholangitis, biliary colic, hepatitis, duodenal ulcer, pneumonia
Left upper quadrant pain\: splenic pain (enlargement, infarction, rupture)
Right iliac fossa pain\: appendicitis, Crohn’s disease, ectopic pregnancy, renal stone, mesenteric adenitis, torsion of
ovarian cyst
Left iliac fossa\: diverticulitis, ectopic pregnancy, ulcerative colitis, incarcerated hernia, torsion of ovarian cyst
Flank pain\: renal colic and pyelonephritis
Suprapubic pain\: urinary tract infection, testicular torsion, miscarriage, pelvic in
For more information, see our guide to abdominal pain history taking.
Gastrointestinal risk factors
When taking a gastrointestinal history it's essential that you identify risk factors for gastrointestinal disease as you work
through the patient's history (e.g. past medical history, family history, social history).
Important gastrointestinal risk factors include\:
Pre-existing gastrointestinal disease (e.g. GORD, Crohn's disease)
Family history of gastrointestinal disease (e.g. familial adenomatous polyposis)
Alcohol
Smoking
Recreational drugs
Diet

Ideas, concerns and expectations

A key component of history taking involves exploring a patient’s ideas, concerns and expectations (often referred to as ICE) to
gain insight into how a patient currently perceives their situation, what they are worried about and what they expect from the
consultation.
The exploration of ideas, concerns and expectations should be
This will help ensure your consultation is more natural, patient-centred and not overly formulaic.
It can be challenging to use the ICE structure in a way that sounds natural in your consultation, but we have provided several
examples for each of the three areas below.
Ideas
Explore the patient's ideas about the current issue\:
" W h a t d o y o u t h i n k t h e p r o b l e m i s ?"
" W h a t a r e y o u r t h o u g h t s a b o u t w h a t i s h a p p e n i n g?"
" I t’ s c l e a r t h a t y o u’ v e g i v e n t h i s a l o t o f t h o u g h t a n d i t w o u l d b e h e l p f u l t o h e a r w h a t y o u t h i n k m i gh t b e go i n g o n .
"
Concerns
Explore the patient's current concerns\:
" I s t h e r e a n y t h i n g , i n p a r t i c u l a r , t h a t’ s w o r r y i n g y o u ?"
" W h a t’ s y o u r n u m b e r o n e c o n c e r n r e ga r d i n g t h i s p r o b l e m a t t h e m o m e n t ?"
" W h a t’ s t h e w o r s t t h i n g y o u w e r e t h i n k i n g i t m i gh t b e ?"
Expectations
Ask what the patient hopes to gain from the consultation\:
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" W h a t w e r e y o u h o p i n g I’ d b e a b l e t o d o f o r y o u t o d a y ?"
" W h a t w o u l d i d e a l l y n e e d t o h a p p e n f o r y o u t o f e e l t o d a y’ s c o n s u l t a t i o n w a s a s u c c e s s ?"
" W h a t d o y o u t h i n k m i g h t b e t h e b e s t p l a n o f a c t i o n ?"

Summarising

Summarise what the patient has told you about their presenting complaint. This allows you to check your understanding of
the patient's history and provides an opportunity for the patient to correct any inaccurate information.
Once you have summarised, ask the patient if there’s anything else that you’ve overlooked. Continue to periodically
summarise as you move through the rest of the history.

Signposting

Signposting, in a history taking context, involves explicitly stating what you have discussed so far and what you plan to
discuss next. Signposting can be a useful tool when transitioning between di
provides the patient with time to prepare for what is coming next.
Signposting examples
Explain what you have covered so far\:
a c h i e v e t o d a y .
"
" O k , s o w e’ v e t a l k e d a b o u t y o u r s y m p t o m s , y o u r c o n c e r n s a n d w h a t y o u' r e h o p i n g w e
What you plan to cover next\:
h i s t o r y .
"
" N e x t I’ d l i k e t o q u i c k l y s c r e e n f o r a n y o t h e r s y m p t o m s a n d t h e n t a l k a b o u t y o u r p a s t m e d i c a l

Systemic enquiry

A systemic enquiry involves performing a brief screen for symptoms in other body systems which may or may not be relevant
to the primary presenting complaint. A systemic enquiry may also identify symptoms that the patient has forgotten to mention
in the presenting complaint.
Deciding on which symptoms to ask about depends on the presenting complaint and your level of experience.
Some examples of symptoms you could screen for in each system include\:
Systemic\: fevers, weight change, fatigue
Cardiovascular\: chest pain, oedema, syncope, palpitations
Respiratory\: dyspnoea, cough, sputum, wheeze, haemoptysis, pleuritic chest pain
Genitourinary\: oliguria, polyuria, dysuria, urinary frequency
Neurological\: visual changes, motor or sensory disturbances, headache, confusion
Musculoskeletal\: chest wall pain, trauma
Dermatological\: rashes, skin lesions, jaundice

Travel history

If the patient’s symptoms are suggestive of an infective aetiology (e.g. infective diarrhoea, hepatitis, malaria) take a thorough
travel history\:
Area of travel\: note areas with a high prevalence of speci
Diet\: ask the patient if they recently ate any high-risk food in these areas (e.g. salmonella).
Insect bites\: ask if the patient noticed any insect bites (e.g. mosquito bites preceding malarial symptoms).
Contact with contaminated water\: ask the patient if they ingested water that may have been contaminated (e.g. swimming
in contaminated water).

Past medical history

Ask if the patient has any medical conditions\:
" D o y o u h a v e a n y m e d i c a l c o n d i t i o n s ?"
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" A r e y o u c u r r e n t l y s e e i n g a d o c t o r o r s p e c i a l i s t r e g u l a r l y ?"
If the patient has a medical condition, you should gather more details to assess how well controlled the disease is and
what treatment(s) the patient is receiving. It is also important to ask about any complications associated with the condition
including hospital admissions.
Ask if the patient has previously undergone any surgery or procedures (e.g. bowel resection, endoscopy, colonoscopy)\:
" H a v e y o u e v e r p r e v i o u s l y u n d e r g o n e a n y o p e r a t i o n s o r p r o c e d u r e s ?"
" W h e n w a s t h e o p e r a t i o n / p r o c e d u r e a n d w h y w a s i t p e r f o r m e d ?"
" W h a t w e r e t h e r e s u l t s o f t h e c o l o n o s c o p y / e n d o s c o p y ?"
Allergies
anaphylaxis).
Ask if the patient has any allergies and if so, clarify what kind of reaction they had to the substance (e.g. mild rash vs
Examples of relevant medical and surgical history
Past medical history relevant to gastrointestinal disease\:
Endoscopy and colonoscopy dates and results
Iron de
B12 de
Irritable bowel syndrome
Constipation
Crohn's disease
Ulcerative colitis
Abdominal malignancy
Gastroesophageal re
Coeliac disease
Colonic polyps
Diverticular disease
Non-alcoholic fatty liver disease
Liver cirrhosis
Gallstones
Past surgical history relevant to gastrointestinal disease\:
Abdominal surgery (e.g. cholecystectomy, bowel resection)
Previous bowel obstruction
Stoma formation

Drug history

Ask if the patient is currently taking any prescribed medications or over-the-counter remedies\:
“ A r e y o u c u r r e n t l y t a k i n g a n y p r e s c r i b e d m e d i c a t i o n s o r o v e r-t h e-c o u n t e r t r e a t m e n t s ?”
If the patient is taking prescribed or over-the-counter medications, document the medication name, dose, frequency, form
and route.
Ask the patient if they're currently experiencing any side e
jaundice secondary to antibiotics)\:
" H a v e y o u n o t i c e d a n y s i d e e
Ask the patient (if relevant) if they are using any form of contraception and if there is any chance they could be pregnant
(ectopic pregnancy commonly presents with abdominal pain)\:
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" A r e y o u c u r r e n t l y s e x u a l l y a c t i v e ?"
" A r e y o u u s i n g a n y f o r m o f c o n t r a c e p t i o n ?"
" I s t h e r e a n y c h a n c e y o u c o u l d b e p r e g n a n t ?"
Commonly prescribed gastrointestinal medications
Medications commonly prescribed to patients with gastrointestinal disease include\:
Laxatives (e.g. senna, docusate)
Loperamide
Sodium alginate/calcium carbonate (e.g. Gaviscon)
Proton pump inhibitors (e.g. lansoprazole)
H2 receptor antagonists (e.g. famotidine)
Hyoscine butylbromide
Immunosuppressants (e.g. corticosteroids, ciclosporin, methotrexate, biologics)
Some over-the-counter drugs which may impact the gastrointestinal system include\:
Aspirin (may worsen gastrointestinal bleeding)
NSAIDs (may cause gastric/duodenal ulceration)
St John's Wort (an enzyme inducer which may alter the clearance of prescribed medications)
Medications with gastrointestinal side e
Medications with gastrointestinal side e
Opiates (constipation, nausea)
Antibiotics (diarrhoea)
Iron supplements (nausea, abdominal pain, diarrhoea or constipation)
Ondansetron (constipation)

Family history

Ask the patient if there is any family history of gastrointestinal disease (e.g. bowel cancer, haemochromatosis, in
bowel disease, hereditary nonpolyposis colorectal cancer, familial adenomatous polyposis)\:
" D o a n y o f y o u r p a r e n t s o r s i b l i n g s h a v e a n y l i v e r o r b o w e l p r o b l e m s ?"
If one of the patient's close relatives are deceased, sensitively determine the age at which they died and the cause of death\:
" I' m r e a l l y s o r r y t o h e a r t h a t , d o y o u m i n d m e a s k i n g h o w o l d y o u r m o t h e r w a s w h e n s h e d i e d ?"
" D o y o u r e m e m b e r w h a t m e d i c a l c o n d i t i o n w a s f e l t t o h a v e c a u s e d h e r d e a t h ?"

Explore the patient's social history to understand their social context and identify potential gastrointestinal risk factors.
General social context
Explore the patient's general social context including\:
the type of accommodation they currently reside in (e.g. house, bungalow) and if there are any adaptations to assist them
(e.g. stairlift)
who else the patient lives with and their personal support network
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what tasks they are able to carry out independently and what they require assistance with (e.g. self-hygiene, housework,
food shopping)
if they have any carer input (e.g. twice daily carer visits)
Smoking
Record the patient's smoking history, including the type and amount of tobacco used.
Calculate the number of 'pack-years' the patient has smoked for\:
pack-years = [number of years smoked] x [average number of packs smoked per day]
one pack is equal to 20 cigarettes
Smoking signiCrohn's
disease.
See our smoking cessation guide for more details.
Alcohol
Record the frequency, type and volume of alcohol consumed on a weekly basis.
Excess alcohol intake increases the risk of gastrointestinal malignancy (e.g. oesophageal and stomach cancer) and the
development of alcoholic hepatitis/cirrhosis.
O
See our alcohol history taking guide for more information.
Recreational drug use
Ask the patient if they use recreational drugs and if so determine the type of drugs used and their frequency of use.
Intravenous drug use is a risk factor for hepatitis.
Gambling
Ask the patient if they gamble and if they feel this is a problem.
Gambling is causative of several decrements to health directly, such as increased sedentary behaviour during the time spent
gambling, poor sleep, reduced levels of self-care and anxiety. Patients with a gambling problem are also more likely to have
substance misuse issues.
1
Problematic gambling can be assessed via the Problem Gambling Severity Index (PGSI).
Diet
Ask what the patient's diet looks like on an average day and if the patient has noticed any food category that triggers or
worsens their symptoms.
A low-
Patients with coeliac disease may report abdominal pain, nausea and diarrhoea when eating gluten-containing foods. Patients
with biliary colic may report that fatty foods trigger right upper quadrant pain.
Exercise
Ask if the patient regularly exercises (including frequency and exercise type).
Sexual history
If considering blood-borne viruses such as hepatitis, ask the patient about their sexual history to assess their risk.
See our guide to taking a sexual history for more details.

Closing the consultation

Summarise the key points back to the patient.
Ask the patient if they have any questions or concerns that have not been addressed.
Thank the patient for their time.
Dispose of PPE appropriately and wash your hands.
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Reviewer

Dr Lara Stewart
GP
1. References
World Health Organisation. T h e e p i d e m i o l o g y a n d i m p a c t o f g a m b l i n g d i s o r d e r a n d o t h e r ga m b l i n g-r e l a t e d h a r m . 26-28 June 2017. Available from\: [LINK].
Published
Source\: geekymedics.com
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