History
Food and its digestion are probably the earliest subjects of human discourse. It is not surprising that the alimentary system presents more symptoms than all the other systems put together. In evaluating a symptom related to this system, you must diligently pursue the three following features:
I) Precision. Ask the patient what exactly he means and how he would describe the symptom. This is especially important for terms in common everyday use. For example, indigestion may mean different things to different people:
• Stomach pain
• Fullness
• Discomfort
• Nausea
• Vomiting
• Hunger pains
• Loss of appetite
• Heartburn
• Swallowing difficulties
You need an exact description of it from your patient. Avoid leading questions. If the patient is vague, try to define the limits of his imprecision. «Feeling un-well» can become a general abdominal discomfort and «heartburn» anything from acidity to a sticking sensation in the lower gullet.
II) Behaviour. Once the meaning of a symptom is analysed establish the factors which evoke and relieve it. In particular concentrate on its four major characteristics (Table 47). This defines the character of the symptom and clarifies its meaning.
Table 47. Key features of a symptom
1. Nature - exact description, character, location and radiation (if relevant)
2. Onset - relation to food and hunger, provoking factors
3. Frequency and periodicity
4. Relief - relation to food, vomiting, flatus and defecation
III) Associated symptoms. Accompanying symptoms related to the presenting complaints in the alimentary system are essential. Thus, although isolated vomiting is seldom significant, organic disease must be excluded if it is associated with symptoms such as weight loss or anorexia.