GIT History Taking Proforma Flashcards
1
Q
History of Presenting Complaint
A
Site Onset Character Radiation Alleviating Factors Timing Exacerbating Factors Severity
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
3
Q
Other Factors to Consider
A
Fever / Night Sweats Weight loss / gain Appetite Fatigue / Tiredness Malaise Sleep Rashes*
4
Q
If relevent?
A
Sexual / Menstrual History
5
Q
Medications and Allergies
A
Prescriptions
OTC
Herbal
Allergies and Intolerances
6
Q
Past Medical History
A
Inflammatory Bowel Disease
Past GI Bleeds
Surgical Procedures
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.
8
Q
Family History
A
Inflammatory Bowel Disease
Bowel Cancers
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