The GI History

Dysphagia

• Transfer dysphagia is characterized by coughing, choking, or nasal
• regurgitation. If present ask about cranial nerve symptoms.
• Esophageal dysphagia is characterized by sticking further down. The
• patient often perceives food as sticking higher up than it actually does.
• Onset, frequency, intermittent vs progressive
• Solids, liquids, both
• What happens when food sticks ? Does it pass with repeated swallows ?
• Do they need to drink water ? Special maneuvers (eg lift arms up).
• What proportion of the time do they bring it up ?
• Have they had to modify their diet ? (Solids & liquids vs mechanical soft vs liquid)
• Zenker’s: lump in neck, gurgling sound
• Other: weight loss, GERD symptoms (current or past), odynophagia (pain with swallowing), globus (feeling of a constant lump in the throat)

GERD

• Symptoms:
  • Heartburn – retrosternal burning
  • Reflux – bitter taste at back of mouth
  • Other – waterbrash (rare) – fits of oral secretion +/- triggered by reflux
• Onset, frequency, progression
• Timing: time of day, relation to meals, duration, evening, does it wake the pt.
• Treatments: drugs, doses, duration, response
• Risk factors: nicotine, caffeine, smoking, chocolate, peppermint, alcohol
• Systemic diseases: diabetes, scleroderma, other connective tissue disease, Raynaud’s
• Extra-esophageal manifestations: cough, hoarseness, sore-throat, dental erosions, globus, pneumonia

Nausea / Vomiting

• Onset, frequency, progression, viral illness
• Timing: time of day, relation to meals, stress, etc
• Characteristics:
  • Food vs gastric secretions/bile
  • Have they clearly seen food from the day before
  • blood (hematesis)
• SBO symptoms: acute onset, associated pain, stop passing gas. Suddenly resolves +/- ‘diarrhea’
• Complications: lightheaded, hospitalizations, weight loss, proportion of food kept down
• Treatments & response
• Systemic diseases: diabetes, scleroderma, other connective tissue disease, Raynaud’s
• Associated symptoms: diarrhea, headaches, cranial nerve
• Need to differentiate from regurgitation which is the non-forceful bringing up of recently ingested food.

Abdominal Pain – PQRST

• P – provocation – meals, movement, bowel movements
• P – palliations – treatments & response
• Q – quality – dull/sharp, steady/crampy
• R – radiation (where does it go to)
• S – severity – scale of 1 to 10, effect on their function
• T – timing – frequency, duration, course & progression
• Associated symptoms: vomiting, passing gas pr etc

Constipation

• Onset, progression, frequency of BMs (‘anything coming out’)
• Character – change in form, scyballous (like pellets)
• Straining, digital disimpaction, incontinence, ER visits
• Obstructive (strain with no response) vs inertia (don’t get the urge to go)
• Associations: blood, melena, pain (? Relieved by BM), nausea/vomiting,
• Weight loss, abuse (physical, sexual, emotional), Raynaud’s
• Diet (fiber), fluid, exercise
• Treatments & response

Diarrhea & IBD

• Onset, course, progression
• BMs: frequency (day/night), consistency, blood (trace, 25%, 50% etc), cramps, tenesmus (feel they need to go, but nothing comes out)
• Treatments & response (note dose & duration)
• Extra-intestinal manifestations of IBD : painful red eyes, arthritis, low back pain, ulcers (skin, oral)
• Risk factors: travel, untreated water, new medications
• Steatorrhea: float or sink, how many times need to flush, see oil, smell
• Other: surgeries, family history IBD, recent NSAIDs
• IBD Rx: Dose, duration, compliance, response, hospitalisations

Abnormal LFTs

• Past history, knowledge
• Risk factors: Tattoo, acupuncture, IV drug abuse, alcohol, blood transfusion, STDs, multiple sexual partners, cocaine (nasal), herbal products, new medications (even a single dose), travel, family history
• Symptoms: jaundice, itching, sleep reversal
• Chronic liver symptoms: bleeding, increased abdominal girth

GI Bleeding

• Eyeball patient +/- orthostatics – are they stable ?
• Onset, progression, frequency, last event
• Hematemesis, coffee emesis, hematochezia (red), melena
• Complications: presyncope (postural lightheadedness), syncope (lost consciousness), chest pain, SOB
• Risk factors: ASA, NSAIDs, ‘anti-inflammatories’, coumadin, steroids, SSRIs
• History: PUD, bleeds, AAA repair, IBD, anemia, any other GI symptoms
• OK to scope: symptoms of angina, CHF, need SBE prophylaxis ?