Outpatient GI
Assess
Page Contents
Gathering Data for An Assessment
Before asking the patient questions for your assessment, make sure to introduce yourself and set the agenda for the discussion. When gathering data for your assessment, collect information on the patient’s:
- Clinical Data: medical, social/lifestyle, and GI histories
- Anthropometric Data
- Biochemical Data
- Dietary Data
Case Study: Meet Christian
Clinical Data
Medical History
When gathering clinical data, consider the following details.
- Type and duration of diagnosis: Do they have a diagnosis? What has their family doctor discussed with them? If they do not have a specific diagnosis, what concern are they seeing you for? Do they regularly see any specialists?
- Previous tests or procedures: Have they had a scope, motility tests, or breath tests? What was the result?
- Family’s medical history: Did members of their family have the same diagnosis or other medical conditions?
- Other medical conditions they may have: e.g. hypertension, dyslipidemia, cardiovascular disease, schizophrenia, depression, bipolar disorder, polycystic ovary syndrome (PCOS), sleep apnea, etc. Consider overlap or controversies of recommendations.
- Symptoms and complications: What are their symptoms? How is it affecting their quality of life? Do they notice any links between symptoms and dietary choices or behaviour?
- Medications and supplements: Are they on any related medications? Are they taking any supplements (Metamucil, probiotics, vitamins, etc.)?
Christian’s Medical History
- Diagnosis:
- GERD – diagnosed 8 years ago. Through your discussion, Christian tells you he recently noticed his symptoms worsening and the doctor prescribed him medication.
- IBS – diagnosed 1 month ago. Christian reports this is the main reason he is seeing you today.
- Family’s medical history: Type 2 diabetes.
- Medications and supplements:
- 20 mg Esomeprazole (Nexium) – started 4 weeks ago
- Metamucil – as directed once daily
- 1000 IU vitamin D once daily
Social and Lifestyle History
When gathering social and lifestyle data, consider the following details.
- Housing: What is their living situation? Do they live with others/have a support system?
- Employment: Are they currently working? What do they do for work? Is it stressful? What does a typical day look like?
- Income: What is their main source of income? Do they have medical coverage?
- Substance use: Smoking? Alcohol? Any other substances?
- Food security: Can start with “where do you get your groceries”. More specific food security questions may include “Have anyone in your household gone without food in the past month because they couldn’t afford it?”
- Physical activity: Do they exercise? What is their routine Do they have an injury or live in an unsafe area making it difficult to get outside to exercise?
- Stress: How would they rank their stress? How does stress affect them?
- Sleep: How long do they sleep for? How is their quality of sleep?
Christian’s Social and Lifestyle History
- Housing: Lives with his fiancee, Caitlyn.
- Employment: Christian is a lawyer and his fiancee works in sales.
- Income: Has medical coverage for his medication.
- Substance use: does not smoke, drinks 1-2 glasses of red wine per night
- Food security: reports no concerns. Caitlyn is doing most of the groceries and cooking since Christian has been busier with work.
- Physical activity: typically goes to the gym 2 times per week for an hour (~120 mins per week on average). He finds enjoyment in exercise and it helps him relax. He tries to get outside to do activities when weather and time permit.
- Stress: He reports his job as being stressful (long hours, limited breaks).
- Sleep: 5-6 hours per night. His sleep quality is not great, attributed to the stress of his job and planning for his and Caitlyn’s upcoming wedding.
GI History
You should always ask a new client a few basic GI-related questions (e.g. do you have any concerns regarding your digestion? do you have normal bowel movements?). However, if you are working with a client that is seeing you for a specific GI-related concern, it is important to ask more specific questions, which may include, but are not limited to the following:
- Do you see any GI specialists? What has your family doctor talked to you about regarding your symptoms? Have you had any testing done for your concerns? What were the results (if you do not have access to this information in your practice)?
- What are your symptoms? Any pain, vomiting, nausea, bloating, or gas? How often do your symptoms occur? Where are your symptoms (i.e. lower left side)?
- When did the symptoms start? Did you notice any triggers?
- How are your bowel movements? Have you noticed any mucous, greasy lining or blood in your stool? What is the consistency? Note: you should explore what these symptoms may suggest and why you should ask about them.
- Do you keep a journal of your symptoms? Have you noticed any common triggers for your symptoms (what you eat, your environment, how you feel that day)?
Christian’s GI History
- Testing: Christian reports being tested by his family doctor for various GI diseases. He had an upper endoscopy, which resulted in his GERD diagnosis. He has completed blood work, a CT scan, and a colonoscopy over the past 6-months to a year related to his new symptoms. There were no findings. The doctor diagnosed his with IBS 1 month ago.
- Symptoms: Regarding his GERD, he experienced an improvement while on the medications (previous symptoms included heartburn, regurgitation, and hiccups), but reports increased bloating as side effects since starting the medication. He would like to control his reflux symptoms without medication as he was made aware of the long-term effects related to the use. Regarding his IBS, he reports pain in his entire abdomen approximately 15 minutes after eating (if he experiences symptoms), which occurs 3-5 times per week. This is followed by diarrhea, which does help relieve the pain. Over the past year, he has noticed that he goes to the bathroom more often, experiences a ”urgency” sensation and has more “diarrhea”.
- Bowel movements: Normally stool is soft but formed, unless he is having these mentioned symptoms, in which case it is watery and loose. He reports rectal pressure and pain with bowel movements due to an anal fissure. Every time there is increased pressure and pain, there is also bright red blood in the stool due to the fissure. No reports of mucous or greasy lining in stool. He goes to the bathroom once a day on average, but when experiencing symptoms it may increase.
- Triggers: No known triggers. Christian enjoys eating various foods (i.e. does not eat the same thing every day) and eating out. He has never kept a food journal.
Anthropometric Data
When gathering anthropometric data from the client, consider the following details.
- Weight: Current weight in kg
- Waist Circumference: Current waist circumference in cm.
- Height: Current height in cm
- Body Mass Index (BMI)
- Weight History: Has their weight recently fluctuated? What was their highest and lowest adult body weight?
It’s important to ask if the client is comfortable having these measurements taken as this may trigger stress for some clients. If you feel it is relevant, you should approach the conversation in a respectful manner and be cautious not to offend your client. If the client states that weight loss is a goal for them, it can be helpful to know:
- Why that goal is important for them
- If they have tried to lose weight before
- Any diets they have tried in the past
- How their weight has fluctuated over the years
Christian’s Anthropometric Data
- Weight = 74 kg
- Height = 183.5 cm
- BMI = 22 kg/m2
- Weight History: He has no concerns about his weight, which has remained stable throughout his life. He has never tried any diets. Christian considers his food choices healthy.
Biochemical Data
It is important to review any available lab work, even if it is not directly related to the condition or concern that your client is seeing you for.
Christian’s Biochemical Data
Here are the lab values for Christian. These labs are from one month ago. This is the information you have available to you based on his recent lab work.
| Lab Test | Lab Result | Target Range |
|---|---|---|
| A1C | 4.5% | < 5.7% |
| TC | 3.1 mmol/L | < 4.0 mmol/L |
| LDL | 1.45 mmol/L | < 2.0 mmol/L |
| HDL | 1.9 mmol/L | > 1.0 mmol/L |
| TG | 1.0 mmol/L | < 1.7 mmol/L |
| Serum iron | 55 mcg/dL | 60 – 170 mcg/dL |
| Serum ferritin | 19 mcg/L | < 15 ug/L – iron deficiency
15-30 ug/L– probable iron deficiency >30 ug/L – iron deficiency unlikely >100 ug/L – normal iron stores |
| Vitamin B12 | 230 ng/mL | 230 – 900 ng/mL |
| Folate | 7 ng/mL | >8.7 ng/mL |
As Christian is your client, it is important to review any available lab work, even if it is not directly related to the condition or concern (e.g. note the A1C value, as he mentioned a family history of type 2 diabetes).
While reviewing Christian’s laboratory data, you recall him mentioning that he is extremely tired and experiences headaches and lightheadedness. Christian reports that he has attributed this to his lack of sleep, stress of wedding planning, and busy work schedule. Review Christian’s labs and make note of any concerns you may have. This information will be used in the plan section.
Dietary Data
When gathering dietary data, consider the following details.
- Diet History: 24-hour recall, 3-day food record, and/or food frequency questionnaire (pop, juice, sweets, alcohol, fast food, etc.) Have they tried any diets in the past?
- Eating behaviours: How many meals/day? What times of the day are meals and snacks (i.e. evaluate time intervals)? Eating at home or eating out?
- Food access and skills: Do they have access to a kitchen? Do they get groceries and/or cook at home, or does someone else do the cooking in the household? What is their previous nutrition education? What do they know about managing their symptoms or condition with diet choices?
Christian’s Dietary Data
Eating behaviour:
- Eats 3 meals a day. If he has a snack, it would be at night before bed.
- Eats out 3-4 times a week. Common places include Freshii (salads and rice bowls), ramen noodles, and Greek food.
- Eats at work for lunch, and has started packing dinners to bring to work most of the week as well
Food access and skills:
- Does some grocery shopping and cooking.
- Reports enjoying a variety of healthy foods and believes he maintains a balanced diet.
- Has not received any nutrition education for his concerns
Diet history: no dieting in the past.
Christian’s 24-hour diet recall provides a picture of what he had to eat and drink the day before. You ask him if this represents a typical day. Christian confirms that these meals are representative of a typical day.
| Meal | Christian’s diet recall |
|---|---|
| Breakfast 6 am | Fruit smoothie (strawberries, apple, avocado, kale, cucumber, almond milk), 2 hard boiled egg or ”egg muffins” with spinach mixed in, and 1 large coffee with 2 cream (5%) |
| Lunch 12 pm |
Premade salad or rice bowl (spring mix or brown rice, marinated or spiced baked chicken, cucumber, tomato, green pepper, onion, chick peas or kidney beans, walnuts, and feta or goat cheese with an olive oil dressing or any “light” dressing available), 1 large coffee with 2 cream (5%) |
| Dinner 5 pm |
6 oz baked fish, chicken, or beef, with mixed roasted vegetables (broccoli, cauliflower, asparagus, potatoes cooked in olive oil with garlic, paprika, and other spices), and 1 cup of quinoa, rice, or whole grain pasta |
| snack 11 pm |
1-2 glasses of red wine, 1-2 cookies or 2 cups of popcorn or carrots with red pepper hummus |
Review his 24-hour recall and identify any concerns you may have considering his diagnosis of IBS and GERD, as this will be used in the Plan section.
Common medical abbreviateion for Latin "hora somni", meaning "bedtime".
