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GIT History Cheat Sheet (DRAFT) by

daihjh dapsdd phphhp

This is a draft cheat sheet. It is a work in progress and is not finished yet.

Preper­ation:

W
Wash Hands
I
Introduce Yourself + Patient's Identity
P
Permission
P
Patient Position + Pain
E
Explai­­­n­ation

Basic Patient Inform­ation:

Name
Age
Date of Birth
Gender
Date Seen

Presenting Complaint:

Anorexia and Weightloss
Dysphagia
Nausea and Vomiting
Wind and Flatulence
Abdominal Distension
Pain:
Painful mouth
Heartburn and Reflux
Dyspepsia
Odynophagia
Abdominal Pain

Abdominal Pain:

Visceral Pain:
Poorly localised

Distension, muscle spasm, inflam­mation, anoxia, stretch of mesentry

Foregut visceral pain - Epigastrium
Midgut visceral pain - Periumbilical
Hindgut visceral pain - Hypoga­strium
Somatic Pain:
Well localised

Cutting, pressure, temper­ature, inflam­mation
Character:
• Colicky ➢ Smooth muscle contra­ction of the wall of a hollow organ (bowel) ➢ Sinusoidal (in time) and migrating (in site)
• Constant Dull Ache ➢ Organ with fibrous capsule (liver)
• Burning ➢ Inflam­mation (Oesop­hag­us/­ure­thra)
• Disten­tio­n/f­ull­nes­s/b­ursting
• Constr­ict­ing­/ti­ghtness ➢ Cardiac
• Throbbing ➢ Increasing with each systole (headache)
• Stabbing ➢ Sharp (Pleuritic pain or acute perito­nitis)

Exacer­bating Factors:

Movement:
Inflam­mation of the parietal peritoneum
Food:
Gastric
Increased acidii­ty/­fas­ting:
Duodenal
Exercise:
Muscular
Stretc­h/Deep Inspir­ation:
Pleuritic

Relieving Factors:

Evacuation of Contents:
Smooth Muscle Distention

e.g. Gastric pain relieved by vomiting
Rectal pain relieved by defication
Movement/Application of Heat:
Smooth Muscle Spasm
Sitting Forward:
Pancreatic Pain or Perica­rditis

Associated Symptoms:

Upper GI:
• Dysphagia
• Regurgitation
• Vomiting
• Haemat­emesis (Vomiting Food)
• Fatty Food
• Intolerance
• Flatulence
Lower GI:
• Constipation
• Distension
• Diarrhoea
• Blood/­mucus per rectum
• Tenesmus (A feeling of incomplete evacuation of the bowel)
• Perianal Discomfort
General:
• Anorexia
• Weight Loss
• Symptoms of Anaemia
Altered Bowel Habit:
• Diarrhoea (Ask frequency and consis­tency)
• Consti­pation

Bleeding:
• Haemat­emesis (ask about volume)
• Melaena (black, sticky, tarry, stool)
• Rectal Bleeding (colour, volume, mixed in stool or not?)

Common Disorders:

Upper GIT:
• Oesophagitis
• Gastroduodentitis
• Biliary Colic
• Acute Cholecystits
• Acute Pancre­atitis (Epiga­stric Pain)
Lower GIT:
• Acute Append­icitis
• IBD (RIF Pain - terminal ileitis)
• Colonic or rectal carcinoma (Altered bowel habit or intestinal obstru­ction)
Hepatobiliary:
• Pre-he­patic, hepatic, and post-h­epatic causes of jaundice
Consider associ­ations with other symptoms:
e.g. Left rib fractures 9-11 associated with splenic injury

Conclu­sion:

Ideas, Concerns, and Expect­ations
Thank patient and ensure comfort