Medical History Taking in Gastroenterology & Hepatology Mohssen Nassiri Toosi, MD.

Medical History Takingin

Gastroenterology & Hepatology

Mohssen Nassiri Toosi, MD

Medical History Taking in GI & Liver Disease

What is the purpose of medical history taking?

Patient introduction

Patient main problem understanding

Patient problem solving approach

Patient medical differential diagnosis

Patient problem treatment

Patient satisfaction


Types of medical history taking

Emergent situationsCover patient life first

Out-patient situationCover brief, focused, and problem-oriented history

In-Patient situationCover comprehensive history



Emergent situations

Know emergent situations

Think about emergent situation

Understand emergent situation on a patient

Do emergent actions to cover life

Take emergently-needed history

Resuscitate emergent condition

Take complete comprehensive history



What are Emergent situations

Life-threatening situations

Airways problems

Severe dysphagia and breathing problem due to Food impaction

Breathing problems

Severe chest pain and dyspnea due to Diaphragmatic hernia

Abdominal pain, hypotension and dyspnea due to hydatid cyst

rupture anaphylaxis

Circulation problems

GI bleeding and severe blood loss (massive)

Abdominal pain and shock


Emergent medical history taking

Secure airway, breathing, and circulation

Control vital signs

Open veins for IV access

Take blood sample for examination

Take history to assess severity (Assessment)

Start Resucitation and emergent treatments

Start problem-base history taking


Emergent medical history taking in GI bleeding

Assessment

BP, orthostatic change, PR, skin and mocosa, Urine output

CBC, PLT, BUN, Creatinie, PT (INR), ABO blood group

Resucitation

IV fluid, Oxygen, Appropriate blood product

Start problem-base history taking

PUD, Retching, Drug (ASA) intake, Malignancy,Liver

diasease, surgery, ….



Out-patient situation

Cover briefly focused, problem-oriented history

There is no emergent situation.

Patient is in a stable condition.

This is the first visite.

You know the patient from before.

You have less time for each patient.


Parts of a medical history

Identifications (patient ID)

Chife complaint

Present illness

Past medical history

Review of system

Physical examination

Problem list

Differential diagnosis




name

age

gender

birth place

ethinicity

occupation

education level

marrigae status

family size

Religious

…….




What is its purpose?

Patient introduction

better Patient-problem solving approach

better Patient-problem treatment




Chife complaint (CC)





What is CC?

The main cause of referring patient to doctor

Usually single ( but sometimes more than one )

By patient,s words ( but be sure it is reliable )





What is CC?

The main cause of referring patient to doctor and the most important

complaint for patient

Patient usually has many complaints

Sometimes it is more than one

The main request of patient is important

Sometimes it is not a physical complaint





What is CC?


Usually single

To be main and major not accessory ones

Sometimes it is multiple

Make a syndrome from multiple CCs




Make a syndrome from multiple CCs

JaundiceFeverChillsAbdominal pain

• Abdominal pain• Jaundice• melena

• Sever abdominal pain• Interactible vometing





What is CC?


Usually single

By patient,s words

Not by physician interpretation but by physician guidence

Patient,s words must be reliable and correct

It need mutual conversation and dialoge


Natural event Patient thinking True event

Pale & Yellowishness jaundice Paleness

Decreasing defecations Liver disease constipation

Sensation of food in the throat Dysphagia globus sensation

Dark stool GI bleeding Constipated faeces, Drug (bismuth) or food

Epigastric distention Bowel obstruction or ulcer bloating




Chife complaint

Present illness

What is present illness?

It is to understand better CC.

It consists of all medical history related to CC.

It could include all PMH, DHx, and Lab tests, except physical examination.

It must clear and describe all medcial aspects of CC.

It is main part of medical history.

It must lead to differential diagnosis.




Chife complaint

Present illness

Levels of present illness

Level 1

Level 2

Level 3



Present illness


Level 1

Patient talk and doctor listen

Let patient feels free

Guide patient to talk about CC

It is like a story of CC from patient side

Do not take many time and do not need special

knowledge



Present illness


Level 2

Doctor make fixed question and patient make answer

Base on a prototype questions to describe CC

Can change in different CC

Location, radiation, timing, aggrevating factors, relieving

factors, relations, associations, changing through time

Try to describe CC completely

Need medical knowledge

Prepare for starting differential diagnosis



Present illness


Level 3

Doctor make oriented question and patient make answer

Base on speculated differential diagnosis (D.Dx)

Need generation of differential diagnosis

Need knowledge and study on each D.Dx

Need generation of DD-oriented questions

D.Dx are completed in progress




Chife complaint

Present illness

Past medical history

Review of system

Physical examination

Problem list

Differential diagnosis

D.Dx

D.Dx

D.Dx


Levels of a present illness

Level 1Patient story about CCPatient talk, doctor listen

Level 2Medical description of CCFixed questions about CC

Level 3Completing present illness

D.Dx oriented questions

Better understanding CC

Starting D.Dx

Complete D.Dx

Medical History Taking in Gastroenterology & Hepatology Mohssen Nassiri Toosi, MD.

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