OnExam

Identifying Information

Gather the patient's general identifying data.

Chief Complaint

Elicit the patient's chief complaint or reason for visit.

History of Presenting Illness (HPI)

Characterize each of the patient's principal symptoms using the OPQRST/OLD CARTS approach.

General:

  • Rule out pregnancy
  • Diet/Appetite
  • Fatigue
  • Fever
  • Weight change
  • Recent travel
  • Recent hospitalization/surgeries
  • Risk of food poisoning
  • Sick contacts
  • Recent trauma

Abdominal Pain

  • Visceral pain
    • Difficult to localize
    • Described as burning, cramping, aching, gnawing pain
    • Pain often centrally located in the abdomen in the epigastric (foregut), peri-umbilical (midgut), or suprapubic (hindgut) region due to embryological distribution of visceral pain receptors
  • Parietal pain
    • Severe
    • Localized
    • Patients prefer to lie still (worse with movement)
      • Did they feel every bump on the way to the hospital?
    • Steady, aching pain
  • Referred pain
    • Localized
    • Describe change over time

Nausea and Vomiting

  • Composition of emesis
    • Bile
    • Hematemesis
      • Esophageal or gastric varices, gastritis, or peptic ulcer disease
    • Digested food
    • Undigested food
    • Feculent material
      • Suggestive of bowel obstruction
  • Colour
    • Bile = green-yellow
    • Blood = red/black/coffee-ground appearance
    • Gastric = clear-mucus
  • Timing
    • Morning
      • Consistent with pregnancy or increased intracranial pressure
    • Post-meal
        May indicate gastric outlet obstruction, small bowel obstruction, gastroparesis, bulimia/purging or uremia
    • Work/Environmental Factors
      • Extreme physical activity
      • Heat exhaustion/stroke
    • Related to physical activity
  • Determine possibility of aspiration or significant blood loss
  • Recent alcohol/drug ingestion

Reflux

  • Medications
  • Alcohol intake
  • Associations with postural and typical foods (high fat foods, chocolate, tomatoes)
    • Gastroesophageal Reflux Disease often associated with worsened symptoms while lying down or bending over
  • Rule out cardiac causes

Anorexia

  • Determine food intake/nutritional status
  • Reasons for decreased food intake
  • Desire to eat
  • Weight loss

Bowel Habits

  • Establish baseline bowel habits Bristol Stool Chart
  • Change in frequency
  • Change in caliber of stool (e.g., pencil-like)
  • Stool characteristics
    • Solid/loose
    • Hard/soft
    • Floating
    • Odorous
    • Mucous
    • Oily (steatorrhea)
    • Colour
  • Changes in the colour of stool can be interpreted
    • Black, tarry = melena
      • May be due to upper GI bleed (100mL)
    • Black, non-sticky = iron supplementation
    • Red, bloody = hematochezia (>1000mL)
      • Bright red blood that fills the toilet bowl suggests hemorrhoid rupture
      • Colitis of various etiologies
      • Other rectal sources, blood often found when wiping with toilet paper suggests hemorrhoid
    • Gray/light coloured = acholic
      • Consider liver cirrhosis, hepatitis, cholelithiasis
    • Maroon coloured streaks on stool surface suggest bleed from tumour or diverticuli in sigmoid colon
    • Yellow/greasy = steatorrhea
      • Consider fat malabsorption (i.e. celiac disease)
      • Question recent antibiotic use (Penicillins, Macrolides)
  • Flatulence
  • Bloating

Dysphagia/Odynophagia

  • Worse with solids (mechanical narrowing) or liquids (motility disorder)
  • Location of pain/discomfort
  • Halitosis associated with Zenker's Diverticulum

Jaundice

  • Colour of urine
    • Dark/tea coloured urine with high concentrations of conjugated bilirubin
  • Colour of stool
    • Grey/light colour = acholic stool (may represent obstruction of bile tract/duct)
  • Pruritus (obstructive jaundice/conjugated bilirubinemia or chronic hyperbilirubinemia)
  • Right upper quadrant pain or referred pain in the right shoulder or scapula region
  • Consider Hepatitis A with recent travel or ingestion of contaminated water/food
  • Consider Hepatitis B with exposure to high-risk body fluids of infected partners or occupation related
  • Consider Hepatitis C with IV drug use or blood transfusions
  • Alcohol use, substance abuse see CAGE Questionnaire, and toxic exposures see Recreational Drug History
  • Recent gallbladder surgery/procedures
  • Hereditary disorders

Past Medical History (PMHx)

Specifically ask about:

  • Diseases of the GI and urinary tracts
  • Past surgeries or treatments
  • Previous investigations (i.e., endoscopies, ultrasound, GI series)
  • Last menstrual period see Gynecological History under HPI

Family History (FmHx)

Specifically ask about:

  • Colorectal cancer
  • Gallstone disease
  • Inflammatory Bowel Disease
    • Crohn's, ulcerative colitis
  • Irritable Bowel Disease
  • Celiac disease
  • Primary biliary cirrhosis
  • Ovarian cancer
  • Hepatic cancer
  • Gastric cancers
  • Lymphomas

Social History (SocHx)

Specifically ask about:

  • Travel history
  • Exercise
  • Diet
  • Usage of holistic/naturopathic healthcare

Substance Use History (SubHx)

Medications

Gather complete list, including particularly relevant drugs including:

  • Anticoagulants
  • Recent antibiotics
  • NSAIDs and 5' ASA
  • Corticosteroids
  • Proton pump inhibitors
  • H2 blockers
  • Laxatives
  • Opioids
  • OTC and Herbals
  • If medication side effects are suspected, see following section

Gastrointestinal Side Effects of Medications

Xerostomia
  • Smooth muscle antispasmodics
  • Tricyclic antidepressants
  • Antipsychotics
Gingival hyperplasia
  • Phenytoin
  • Immunosuppressants
  • Calcium channel antagonists
Tooth discolouration
  • Antibiotics (tetracyclines)
Abnormalities of gustation
  • Oral hypoglycemics (metformin)
  • Antibiotic (metronidazole)
  • Amiodarone
  • Corticosteroids
  • Gold salts
Oral ulceration
  • Tacrolimus
  • Hydroxyurea
  • Nicorandil
  • Aldendronate
Inflammation , ulceration and fibrosis of esophagus
  • Antibiotics (tetracycline, clindamycin)
  • Emepronium bromide
  • Potassium chloride
  • Quinidine
  • NSAIDs
  • Bisphosphonates
Esophageal dysmotility
  • Calcium channel antagonists
  • Nitrates
Esophageal infections (e.g. Candida spp.)
  • Antibiotics
  • Corticosteroids
  • Proton pump inhibitors
Gastric or duodenal ulcers
  • NSAIDs
  • Selective serotonin reuptake inhibitors
Pseudomembranous colitis
  • Antimicrobials (penicillin, cephalosporin, clindamycin)
Macroscopic colitis (bloody or non-bloody diarrhea, colonic ulcers, ‘diaphragm-like’ strictures)
  • NSAIDs
Microscopic colitis (non-bloody chronic watery diarrhea
  • NSAIDs
  • Ticlopidine
  • Flutamide
Ischaemic colitis
  • Oral contraceptives containing estrogen
  • Cocaine
  • NSAIDs
  • Diuretics
  • Selective 5-HT3-receptor antagonist
  • Alosetron
  • Vasoactive drugs
Colonic strictures
  • NSAIDs
Constipation
  • Anticholinergics (antispasmodics, antidepressants, antipsychotics)
  • Cation-containing agents (iron supplements, antacids, sucralfate )
  • Neutrally-active agents (opiates, calcium channel blockers, 5-HT3 receptor antagonists, antihypertensives)
Pancreatitis
  • AIDS therapy
  • Antimicrobials
  • Diuretics
  • Immunosuppressives
  • Neuropsychiatric agents
  • Anti-inflammatory agents
  • Calcium
  • Estrogen
  • Tamoxifen
  • ACE inhibitors
  • Simvastatin
Diarrhea
  • Antimicrobials
  • Laxatives
  • Magnesium-containing antacids
  • Lactose or sorbitol containing products
  • NSAIDs
  • Prostaglandins
  • Colchicines
  • Metformin
  • Antineoplastics
  • Antiarrhythmics
  • Cholinergic agents

Allergies

Note allergies and ensure they concord with those listed in the EMR

Immunizations

Note immunization history as described in the Immunization History Section. Especially relevant to the Gastrointestinal History are the hepatitis B, typhoid, hepatitis A, and rotavirus vaccines.

Review of Systems

Conduct a Review of Systems, keeping other etiologies from your differential in mind.

References

  1. Bickley LS, Szilagyi PG. Bates’ Guide to Physical Examination and History Taking. 10th ed. Philadelphia, PA: Wolter Kluwer Health; 2009.
  2. Campbell, P. Constipation: A concordant approach. Nurse Prescribing. 2005; 3(1):24-27.
  3. Eskander A, Kandel C. The Abdominal Exam. In: Lincoln M, McSheffrey G, Tran C, Wong D, ed. Essentials of Clinical Examination Handbook. 6th ed. Toronto, ON: University of Toronto Medical Society; 2010:27-47.
  4. Marx M, ed. Rosen’s Emergency Medicine. 7th ed. Philadelphia, PA: Elsevier; 2010.
  5. Makins R, Ballinger A. Gastrointestinal side effects of drugs. Expert Opin. Drug Saf. 2003; 2(4):421-429.