Zbieranie wywiadu z zakresu układu pokarmowego | Taking a Digestive System History

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“Gastritis”: “Zapalenie żołądka”, “Peptic ulcer disease”: “Choroba wrzodowa żołądka i dwunastnicy”, “Irritable bowel syndrome (IBS)”: “Zespół jelita drażliwego”, “Appendicitis”: “Zapalenie wyrostka robaczkowego”, “Diverticulitis”: “Zapalenie uchyłków jelita”, “Pancreatitis”: “Zapalenie trzustki”, “Nausea”: “Nudności”, “Vomiting”: “Wymioty”, “Gastroenteritis”: “Nieżyt żołądkowo-jelitowy”, “Food poisoning”: “Zatrucie pokarmowe”, “Early pregnancy”: “Wczesna ciąża”, “Gastroparesis”: “Opóźnione opróżnianie żołądka (gastropareza)”, “Liver disease”: “Choroby wątroby”, “Malignancy”: “Nowotwór złośliwy”, “Dehydration”: “Odwodnienie”, “Electrolyte imbalances”: “Zaburzenia równowagi elektrolitowej”, “Diarrhea”: “Biegunka”, “Acute diarrhea”: “Ostra biegunka”, “Chronic diarrhea”: “Przewlekła biegunka”, “Inflammatory bowel disease (IBD)”: “Nieswoiste choroby zapalne jelit”, “Celiac disease”: “Celiakia”, “Stool frequency”: “Częstość wypróżnień”, “Stool consistency”: “Konsystencja stolca”, “Constipation”: “Zaparcia”, “Difficult bowel movements”: “Utrudnione wypróżnienia”, “Low fiber intake”: “Niska podaż błonnika”, “Sedentary lifestyle”: “Siedzący tryb życia”, “Hypothyroidism”: “Niedoczynność tarczycy”, “Diabetes”: “Cukrzyca”, “Heartburn”: “Zgaga”, “Pyrosis”: “Zgaga”, “Gastroesophageal reflux disease (GERD)”: “Refluks żołądkowo-przełykowy”, “Esophagitis”: “Zapalenie przełyku”, “Barrett’s esophagus”: “Przełyk Barretta”, “Bloating”: “Wzdęcia”, “Gas”: “Gazy jelitowe”, “Swallowed air”: “Połykane powietrze”, “Dietary intolerances”: “Nietolerancje pokarmowe”, “Lactose intolerance”: “Nietolerancja laktozy”, “Small intestinal bacterial overgrowth (SIBO)”: “Przerost bakteryjny w jelicie cienkim (SIBO)”, “Fullness”: “Uczucie pełności”, “Distension”: “Wzdęcie”, “Jaundice”: “Żółtaczka”, “Bilirubin levels”: “Poziom bilirubiny”, “Hepatitis”: “Zapalenie wątroby”, “Cirrhosis”: “Marskość wątroby”, “Bile duct obstruction”: “Zamknięcie przewodu żółciowego”, “Dark urine”: “Ciemny mocz”, “Pale stools”: “Odbarwione stolce”, “Itching”: “Świąd”, “Dysphagia”: “Trudności w połykaniu”, “Oropharyngeal dysphagia”: “Dysfagia ustno-gardłowa”, “Esophageal dysphagia”: “Dysfagia przełykowa”, “Esophageal stricture”: “Zwężenie przełyku”, “Achalasia”: “Achalazja”, “Neurological disorders”: “Zaburzenia neurologiczne”, “Malnutrition”: “Niedożywienie”, “Aspiration”: “Zachłystowe zapalenie płuc”, “Rectal bleeding”: “Krwawienie z odbytnicy”, “Hemorrhoids”: “Guzki krwawnicze (hemoroidy)”, “Colorectal cancer”: “Rak jelita grubego”, “Unintentional weight loss”: “Niezamierzona utrata masy ciała”, “Chronic infection”: “Przewlekłe zakażenie”, “Metabolic disorders”: “Zaburzenia metaboliczne”, “Abdominal pain assessment”: “Ocena bólu brzucha”, “Site”: “Lokalizacja”, “Right upper quadrant pain”: “Ból w prawym górnym kwadrancie”, “Gallbladder disease”: “Choroby pęcherzyka żółciowego”, “Hepatic pathology”: “Patologia wątroby”, “Left lower quadrant pain”: “Ból w lewym dolnym kwadrancie”, “Peritonitis”: “Zapalenie otrzewnej”, “Pain onset”: “Początek bólu”, “Sudden onset”: “Nagły początek”, “Chronic issues”: “Problemy przewlekłe”, “Peptic ulcer”: “Wrzód trawienny”, “Cramping pain”: “Kurczowy ból”, “Radiation”: “Promieniowanie bólu”, “Pancreatitis”: “Zapalenie trzustki”, “Aortic aneurysm”: “Tętniak aorty”, “Fever”: “Gorączka”, “Bowel movements”: “Ruchy jelit”, “Exacerbating factors”: “Czynniki pogarszające”, “Relieving factors”: “Czynniki łagodzące”, “Fatty meals”: “Tłuste posiłki”, “Pain relief”: “Łagodzenie bólu”, “Past Medical History”: “Historia chorób pacjenta”, “GERD”: “Refluks żołądkowo-przełykowy”, “Esophagitis”: “Zapalenie przełyku”, “Peptic ulcer disease”: “Choroba wrzodowa”, “Helicobacter pylori”: “Helicobacter pylori”, “NSAID use”: “Stosowanie niesteroidowych leków przeciwzapalnych (NLPZ)”, “Inflammatory bowel disease”: “Nieswoiste zapalenia jelit”, “Crohn’s disease”: “Choroba Leśniowskiego-Crohna”, “Ulcerative colitis”: “Wrzodziejące zapalenie jelita grubego”, “Hepatitis”: “Zapalenie wątroby”, “Liver disease”: “Choroby wątroby”, “Cirrhosis”: “Marskość wątroby”, “Hepatocellular carcinoma”: “Rak wątrobowokomórkowy”, “Pancreatitis”: “Zapalenie trzustki”, “Cholecystectomy”: “Cholecystektomia”, “Bowel resection”: “Resekcja jelita”, “Family History”: “Wywiad rodzinny”, “Colorectal cancer”: “Rak jelita grubego”, “Celiac disease”: “Celiakia”, “NSAIDs”: “NLPZ”, “Proton Pump Inhibitors (PPIs)”: “Inhibitory pompy protonowej (PPI)”, “Opioids”: “Opioidy”, “Herbal Supplements”: “Suplementy ziołowe”, “Alcohol Use”: “Spożywanie alkoholu”, “Smoking”: “Palenie tytoniu”, “Amoebiasis”: “Pełzakowica”, “Giardiasis”: “Lamblioza”, “Food allergies”: “Alergie pokarmowe”, “Shellfish”: “Skorupiaki”, “Dairy”: “Produkty mleczne”, “Drug allergies”: “Alergie na leki”, “Antibiotics”: “Antybiotyki”, “Chemical Exposure”: “Ekspozycja na chemikalia”, “Occupational hazards”: “Zagrożenia zawodowe”, “Closing the Consultation”: “Zakończenie konsultacji”, “Summary of history-taking”: “Podsumowanie wywiadu lekarskiego”, “Physical examination”: “Badanie przedmiotowe”, “Chronic”: “Przewlekły”, “Acute”: “Ostry”, “Sharp”: “Ostry (ból)”, “Dull”: “Tępy (ból)”, “Cramping”: “Kurczowy (ból)”, “Burning”: “Palący (ból)”, “Stabbing”: “Kłujący (ból)”, “Bowel obstruction”: “Niedrożność jelit”, “Malabsorption”: “Zaburzenia wchłaniania”, “Motility”: “Motoryka”, “Remission”: “Remisja”, “Exacerbation”: “Zaostrzenie”, “Gastric irritation”: “Podrażnienie żołądka”, “Peptic ulcers”: “Wrzody trawienne”, “Bleeding”: “Krwawienie” }; // Normalize keys in the dictionary const normalizedWordsToTooltip = {}; for (const [key, value] of Object.entries(wordsToTooltip)) { const cleanedKey = key.replace(/(.*?)/g, ”).trim(); // Remove anything in parentheses normalizedWordsToTooltip[cleanedKey.toLowerCase()] = value; } function processNode(node) { if (node.nodeType === Node.TEXT_NODE && node.nodeValue.trim()) { let content = node.nodeValue; // Regex to match only the main words 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Opening Consultation

Before starting, review the patient’s medical records for relevant musculoskeletal history if available.

Confirm the patient’s identity politely.

Introduce yourself warmly, stating your name and role.

Chief Complaint (CC)

The Chief Complaint (CC) refers to the primary digestive symptom or concern that a patient presents with during a medical consultation. Common complaints related to the digestive system include:

Complaint	Description
Abdominal Pain	Abdominal pain can be localized or diffuse, acute or chronic. Common causes range from gastritis, peptic ulcer disease, and irritable bowel syndrome (IBS) to more severe conditions like appendicitis, diverticulitis, or pancreatitis. The location, intensity, and timing are crucial for diagnosis.
Nausea and Vomiting	Nausea and vomiting are often associated with gastroenteritis, food poisoning, or early pregnancy, but chronic cases may indicate gastroparesis, liver disease, or malignancy. Frequent vomiting can lead to dehydration, electrolyte imbalances, and requires thorough evaluation.
Diarrhea	Diarrhea may be acute or chronic. Acute diarrhea often results from infections, while chronic diarrhea could be due to conditions such as inflammatory bowel disease (IBD), irritable bowel syndrome, or celiac disease. Frequency, consistency, and presence of blood are important details.
Constipation	Constipation refers to infrequent or difficult bowel movements, often related to low fiber intake, dehydration, or sedentary lifestyle. Chronic constipation may be associated with conditions like hypothyroidism, diabetes, or irritable bowel syndrome. Frequency and stool consistency are key.
Heartburn (Pyrosis)	Heartburn is characterized by a burning sensation in the chest or throat, commonly due to gastroesophageal reflux disease (GERD). Persistent heartburn may lead to complications like esophagitis or Barrett’s esophagus, requiring lifestyle changes or medical treatment.
Bloating and Gas	Bloating and excessive gas can result from swallowed air, dietary intolerances (e.g., lactose intolerance), or small intestinal bacterial overgrowth (SIBO). Patients may feel fullness or distension, often aggravated after eating.
Jaundice	Jaundice, or yellowing of the skin and eyes, indicates elevated bilirubin levels and is commonly linked to liver conditions such as hepatitis, cirrhosis, or bile duct obstruction. It often accompanies dark urine, pale stools, and itching.
Dysphagia	Dysphagia can be oropharyngeal or esophageal in origin, caused by conditions like esophageal stricture, achalasia, or neurological disorders. It may lead to malnutrition or aspiration, making detailed assessment critical.
Rectal Bleeding	Rectal bleeding, indicated by blood in stool or on toilet tissue, ranges from benign causes like hemorrhoids to more serious conditions like colorectal cancer or inflammatory bowel disease. The color and amount of blood provide diagnostic clues.
Unintentional Weight Loss	Significant, unexplained weight loss may indicate chronic infection, malignancy, or metabolic disorders. This symptom often accompanies other gastrointestinal complaints, necessitating prompt evaluation to identify underlying causes.

History of Present Illness

The History of Present Illness (HPI) explores the details of the patient’s abdominal pain, including its onset, location, and associated symptoms. Using the SOCRATES assessment of abdominal pain assists in systematic evaluation.

SOCRATES assessment of Abdominal Pain

• S – Site: The location of abdominal pain is essential for diagnosis. Right upper quadrant pain may suggest gallbladder disease or hepatic pathology, while left lower quadrant pain could be due to diverticulitis. Generalized abdominal pain may indicate conditions such as gastroenteritis, peritonitis, or irritable bowel syndrome (IBS).

• O – Onset: Determining when and how the pain started is key to understanding its cause. Sudden onset of severe pain often points to acute conditions like appendicitis, perforated ulcer, or a ruptured abdominal aortic aneurysm, while gradual onset may indicate chronic issues like peptic ulcer disease or IBS.

• C – Character: The nature of the pain—whether it’s sharp, dull, cramping, burning, or stabbing—can provide valuable diagnostic information. Sharp or stabbing pain might suggest acute peritonitis or pancreatitis, while cramping pain could indicate bowel obstruction or gastroenteritis.

• R – Radiation: Establishing whether the pain radiates to other areas helps refine the diagnosis. For instance, pain radiating to the back may indicate pancreatitis or aortic aneurysm, while pain that moves to the right shoulder could suggest gallbladder disease.

• A – Associated Symptoms: Additional symptoms like nausea, vomiting, fever, or changes in bowel movements can help pinpoint the diagnosis. For example, fever with abdominal pain may suggest an infectious process such as diverticulitis, while vomiting with pain is common in gastroenteritis or bowel obstruction.

• T – Timing: Identifying when the pain occurs and any patterns or fluctuations over time is useful. Pain that worsens after meals could indicate peptic ulcer disease, while early morning pain relieved by food may be related to duodenal ulcers.

• E – Exacerbating/Relieving Factors: Understanding what makes the pain worse or better is essential for diagnosis. Pain that worsens after fatty meals may suggest gallbladder disease, while relief with bowel movements could indicate IBS. Position changes may relieve or exacerbate pain in cases like pancreatitis.

• S – Severity: Asking the patient to rate their pain on a scale from 0 to 10 helps assess its impact on daily life and prioritize management. Severe, debilitating pain may indicate an acute emergency, whereas moderate or fluctuating pain might suggest a chronic condition.

Past Medical History

Understanding the patient’s past medical history for the digestive system is essential for identifying potential risk factors and comorbidities that may contribute to or exacerbate symptoms.

• Gastroesophageal Reflux Disease (GERD): A history of GERD may indicate chronic acid exposure in the esophagus, contributing to conditions like esophagitis or Barrett’s esophagus.
• Peptic Ulcer Disease (PUD): Previous diagnosis of PUD, often due to Helicobacter pylori infection or NSAID use, increases the risk of recurrence, especially if lifestyle factors remain unchanged.
• Irritable Bowel Syndrome (IBS): Patients with IBS often experience chronic symptoms that can mimic other gastrointestinal conditions, so a history of IBS provides context for functional bowel symptoms.
• Inflammatory Bowel Disease (IBD): Conditions such as Crohn’s disease or ulcerative colitis have periods of remission and exacerbation, impacting digestive health significantly.
• Hepatitis: A history of hepatitis (A, B, or C) can lead to chronic liver disease, cirrhosis, or hepatocellular carcinoma, which can manifest with gastrointestinal symptoms.
• Pancreatitis: Previous episodes of pancreatitis, especially if recurrent or chronic, suggest a predisposition to digestive enzyme insufficiency and nutrient malabsorption.
• Surgery: Past abdominal surgeries, such as cholecystectomy or bowel resections, may lead to adhesions or motility issues, affecting digestion.

Family History

A family history of digestive disorders can reveal hereditary patterns, increasing the likelihood of similar conditions.

• Colorectal Cancer: A family history of colorectal cancer significantly raises the patient’s risk, especially if the diagnosis was in a first-degree relative before age 50.
• Celiac Disease: Family history increases the likelihood of gluten sensitivity or autoimmune enteropathy.
• Inflammatory Bowel Disease (IBD): Family members with IBD suggest a higher genetic predisposition for Crohn’s disease or ulcerative colitis.
• Liver Disease: Family history of liver conditions, including cirrhosis or fatty liver disease, may suggest genetic susceptibility.

Medications

Understanding current and past medications helps in identifying possible causes of digestive symptoms related to drug side effects.

• NSAIDs: Long-term NSAID use can cause gastric irritation, peptic ulcers, and, occasionally, bleeding.
• Antibiotics: Some antibiotics may disrupt gut flora, leading to symptoms like diarrhea or predisposition to Clostridioides difficile infections.
• Proton Pump Inhibitors (PPIs): Chronic PPI use may increase the risk of small intestinal bacterial overgrowth (SIBO) or nutritional deficiencies.
• Opioids: These can slow gastrointestinal motility, leading to constipation or abdominal discomfort.
• Herbal Supplements: Some herbs or over-the-counter supplements can cause GI upset or interact with prescribed medications, affecting digestive health.

Social History

A detailed social history helps to identify lifestyle factors that impact digestive health.

• Alcohol Use: Excessive alcohol consumption can damage the liver, pancreas, and stomach lining, increasing the risk of gastritis or pancreatitis.
• Diet: High-fat, low-fiber diets can aggravate conditions like GERD or constipation, while diets rich in trigger foods can worsen IBS symptoms.
• Smoking: Smoking affects digestive health by increasing the risk of GERD, peptic ulcers, and some cancers, especially esophageal and stomach cancers.
• Substance Use: Certain substances, like cocaine or stimulants, can impair gastrointestinal motility and blood flow, leading to GI symptoms.
• Travel: Recent travel, particularly to regions with endemic GI infections, raises the possibility of infections like amoebiasis or giardiasis.

Allergies

Assessing allergies is crucial for managing and understanding digestive symptoms, particularly food and drug allergies.

• Food Allergies: Allergies to specific foods, such as shellfish, nuts, or dairy, can cause acute or delayed GI symptoms.
• Drug Allergies: Allergies to antibiotics or other drugs, such as NSAIDs, may lead to GI upset or contraindications for certain treatments.

Environmental and Occupational Exposures

Environmental and occupational exposures can influence digestive health and exacerbate symptoms.

• Chemical Exposure: Exposure to certain chemicals or pesticides can cause digestive distress or increase the risk of conditions like gastritis.
• Occupational Hazards: Jobs involving heavy metals, toxins, or chemical solvents may increase the risk of hepatic or pancreatic toxicity, impacting digestion.

Closing the Consultation

Summarize the main points discussed during the history-taking to confirm understanding and ensure no details were missed.

Ask the patient if they have any remaining questions or concerns before moving forward with the examination.