Category: Teaching

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 ?