A. HISTORY
A good history is of extreme importance in obtaining an accurate diagnosis
80% of the diagnosis is made from history alone
90% of the diagnosis is made from history and physical examination
Only 10% of the time are special diagnostic procedures required to establish thediagnosis16.01.2001
HISTORY: General Considerations
Nutrition: food intake, weight gain
(thyroid dz, endocrine dz, diabetes, etc.)
or loss
(malignancies)
(5-10% of body weight w/in 6 months w/out trying to lose weight)
Medications
(side effects, interfere w/ absorption of certain nutrients, can also beassociated w/ aggressive GI infection)
Alcohol intake
(prominent effect on GI, and GU dz)
Pregnancy
(Gravida = how many times been pregnant, Para = # of live births, Aborta =# of elective or spontaneous abortions)
Stool characteristics
(color, consistency, smell, frequency, blood, texture, bowel movement (BM), pain w/ defecation, frequency, food digested or not, buoyancy = fat in stool
floats)
Urinary characteristics
(color, appearance: clear, cloudy, etc., frequency: pain?, smell
sweet
ketones, incontinence, dysuria = pain, oliguria = some)
Stressful like events
Recent infectious diseases
Trauma
(seatbelt injuries, car accidents, etc.)
HISTORY: Chief Complaints
GI symptoms:
Abdominal pain
(OPPQRST)
•
Crampy abdominal pain assoc w/ obstruction or poor peristalsis in ahollow tube, Distension causes the pain
Indigestion
(aka Dyspepsia = Heartburn)
Nausea
(Associated w/ every GI disorders
•
Nausea center located in …….. FIND OUT !
•
Reversed peristalsis
Diarrhea
(frequent liquid stools)
•
Viral gastroenteritis
Constipation
(decrease in the volume of stools)
Fecal incontinence
(cause: aging, stroke, spinal cord dz, cauda equina syndrome,etc.)
Jaundice
(yellow skin,
↑
of bilirubin in the blood, Itching)
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