Git History/ Examination - Clinical Skills

Front 1

List the presenting symptoms you would elicit from a patient presenting with abdominal pain.

Back 1

Write SOCRATES down when you go into OSCE as a prompt.

Site of pain, get patient to point and describe.

Onset get patient to describe whether pain came on suddenly or gradually.

Character How does the pain feel? does it feel sharp? Radiate? (next question) Does the pain have a pattern? is it consistent? does it come and go.

Radiation does the pain radiate to other areas or is the pain well localised?

Alleviating factors - Have you found anything that reduces the pain?

Would be good to ask about severity here.

Associated symptoms - BNB LA

bowell

nausea/ vomiting

Bleeding

Liver prblems

Appetite and weight change.

• Changes in bowel habits - diarrhoea, constipation, loose stools, frothy stools, any bloating or visible distention of the stomach.
  
• Nausea/ vomiting/ water brash - timing, frequency, aggrevating and relieving factors
• Bleeding - blood in vomit, are your stools black? Any red blood in the toilet/ on toilet paper?
• Liver problems - jaundice, dark urine, pale stools, pruritis
• Apetite and weight change - "have you had a change in appetite recently? Any loss or gain of weight?" What makes you want to eat less? Do you feel full early/ as soon as you start eating after very little food. Do you get an unpleasant fullness after eating or a feeling that food persists in your stomach for too long? Do you get heart burn. Do you find it difficult to swallow? Worse with liquids or solids.

Timing - does this happen at a particular time of the day. do you have it now (you may have already asked some of these questions.

Exacerbating/ Relieving factors -

Severity - May have already been asked with pain?

Front 2

Besides the eliciting the presenting symptoms what other areas do you need to cover in a GIT history

Back 2

Red flags - MURTAGH

previous episodes

ICE - what particularly are you worried this could be?

Past medical Hx

• Specific - inflammatory bowel disease
  
• GORD
• Hx of endoscopy, coloscopy - results
• Previous surgeries - particularly abdominal surgeries. do you have plans for any surgeries soon?
• last ask general medical hx
• 1

Front 3

What are the specific medical conditions and medications that need to be elicited in the GIT history?

Back 3

Inflammatory bowel disease, GORD, any history of endoscopy,