Gastrointestinal History - Vomiting

Introduction –WIPP
 Wash hands
 Introduce yourself and confirm the patient’s name, age
 Privacy: Insure patient’s Privacy Some questions may be repeated in this
 Permission: Gain consent with explaining what you are guide. Only ask the patient once and
going to do.
don’t repeat the question so you don’t
Presenting complaint (PC) what brought you to the clinic (or ER)?
irritate them.
History of presenting complaint
 Onset and duration
o When did it start? Any history of recent infection or did start after a meal?
o Is it the first time?
o Suddenly or Gradually?
 Character of vomitus
o Bile-colored, rust-colored, bloody etc.
 Associated symptoms
o GI symptoms:
 Early satiety
 Rumination (‫)اجترار‬
 Pain, especially RUQ? Investigate more (SOCRATES)
 Heartburn or GERD
 Ask about coughing, especially when lying down or sleeping
 Upper\lower GIT bleeding (Upper: hematemesis or melena, lower: BRBPR or hematochezia)
 Bloating\abdominal distention
 Dark urine or pale stools?
 Changes in bowel habit i.e. diarrhea\constipation, incontinence
 Weight loss, anorexia, or any appetite changes
o Systemic symptoms
 Halitosis (bad breath)
 Fatigue
 Time: symptoms increasing or decreasing overtime, intermittent or persistent, occurs at a specific time
during the day?
o How many times per day?
 Exacerbating and relieving factors
o Relation to meals
o Medications e.g. antacids
 Severity: did it affect the patient’s daily activities, severity of straining during vomiting
Risk factors was it associated with constitutional symptoms? Ask about weight loss, loss of appetite and fever
Past medical History
 Chronic diseases, e.g. diabetes, hypertension  and how are they controlled (in DM ask about
microscopic, macroscopic etc.)
 Were you diagnosed with a gastrointestinal or hepatobiliary disease before or went to another doctor
for this chief complaint?
o PUD
o Gallstones
o History of IBD
 Previous hospitalization
 STDs or blood-borne diseases (hepatitis, HIV\AIDS)
 Malignancies
 Autoimmune diseases

Past Surgical History

 Have you undergone any type of surgeries?
 Previous blood transfusions

Drug history (DH)

 Find out what medications the patient is taking, dosage, specifically ask about:
o Acetaminophen or NSAIDS
o Antibiotics
o Antacids for heartburn
 Allergies, to medications or others

Family history (FH)

 Has anyone in your family had a similar complain?
 Conditions within the family. Is there any condition that runs in your family, including chronic diseases?
o Any gastrointestinal or hepatobiliary (‫ )أمراض في الكبد أو المرارة‬disease?
o Gallstones
o IBD
o Intestinal polyposis
 Any hereditary disease in general
 Any autoimmune diseases
 Malignancies

Social history (SH)

 Daily performance
 Smoking
 Does he use any illegal substances, e.g. alcohol, cannabis, cocaine, etc.
o Amount of alcoholic drinks per day
o IV drug abuse and sharing needles?
 High-risk sexual activities
 Diet (fatty diet for NASH, unclean food, raw seafood for hepatitis A )
 Occupation (heavy metals or hepatotoxin exposure, or healthcare worker)
 Travel History
Systemic review (see appendix)
Concluding the interview
 Is there anything else you would like to talk about? Then thank the patient