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Gastrointestinal History

From Mediwikis

History of Presenting Complaint

Pain/Discomfort

  • SOCRATES

Dysphagia

  • Pain-Odynophagia

Dyspepsia(indigestion)

  • Nausea

Heartburn

  • Reflux
  • Sour taste in mouth
  • Positioning when it occurs

Vomiting

  • How much
  • How often
  • Colour-green/brown indicates bile
  • Any blood? Haemotemesis

Bowel Habit

  • Changes recently
  • Stool consistency
  • How often per day
    • Normal=3/day to once in 3 days
  • Any Blood

Appetite

  • Change from normal
  • Diet

Weight Loss

  • How much over how long

Itching

  • Jaundice

Abdominal Distension

  • For how long?
  • Onset

Past Medical History

  • Surgery
  • Previous abdominal problems before?
  • Autoimmune conditions

Drug History

  • NSAID use
  • SSRIs
  • Opioids
  • Antibiotics
  • IV Recreational drug use

Family History

  • Ulcerative Colitis
  • Crohn's Disease
  • Colorectal Cancer

Social History

  • Alcohol
  • Smoking
  • Tattoos
  • Travel
  • Blood Transfusions
  • Sexual History
  • Stress