GIT History Taking Proforma Flashcards

1
Q

History of Presenting Complaint

A
Site
Onset
Character
Radiation
Alleviating Factors
Timing
Exacerbating Factors
Severity
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

Associated Symptoms

A
Dysphagia / Onynophagia
Heartburn / Acid Regurgitations / Reflux
Nausea / Vomiting
Haematemesis
Abdominal Pain
Change in Bowel Habit
Malaena / Haematochezia
Jaundice
Dark Urine / Pale Stools
Pruritis
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

Other Factors to Consider

A
Fever / Night Sweats
Weight loss / gain
Appetite
Fatigue / Tiredness
Malaise
Sleep
Rashes*
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

If relevent?

A

Sexual / Menstrual History

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

Medications and Allergies

A

Prescriptions
OTC
Herbal

Allergies and Intolerances

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

Past Medical History

A

Inflammatory Bowel Disease
Past GI Bleeds
Surgical Procedures

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

Social History

A
Marital Status
Living Conditions
Occupation - hapatotoxins, needle stick injuries
Hobbies
Social Supporta

Tattoos
Oversease Travel
Diet

Alcohol - detailed
Smoking
Other substances - IV, oral, etc.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

Family History

A

Inflammatory Bowel Disease

Bowel Cancers

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

Systems Review

A
Constitutional Symptoms: 
Fever / Night Sweats
Weight Loss/Gain
Fatigue . Tiredness
Malaise
Sleep
Rashes / Skin Markings

Neuro: Fits, Faints, Funny Turns, Headaches

CVS: SOB, Dizziness / Syncope, Palpitations, Oedema

Resp: Cough, Wheeze, Haemoptosys

Renal: Increased frequency, urgency, dysuria, oedema

How well did you know this?
1
Not at all
2
3
4
5
Perfectly