23-01-23 – History Taking – GU (Watch lecture for practise questions) Flashcards
Learning outcomes
• To demonstrate an understanding of how patients with GI problems present
• To demonstrate an understanding of the causes of common GI symptoms
• To understand how different body systems inter-relate
• To be able to ask relevant GI questions in a medical history
Watch lecture for practise questions
What 4 histories are included in the genitourinary system (GU)?
• 4 histories included in the genitourinary system (GU):
1) Renal system history
2) Male reproductive system history
3) Female reproductive system history
• Includes menstrual history
• Includes obstetric history
4) Psycho-sexual history
What are the 6 stages of the traditional medical model?
• 6 stages of the traditional medical model:
1) History
2) Examination
3) Investigation
4) Diagnosis
5) Treatment
6) Follow up
What are the 5 stages of the Roger Neighbour Inner Consultation Model 1987?
• This model asks the same questions as the traditional method, but in a different order
• 5 stages of the Roger Neighbour Inner Consultation Model 1987:
1) Connecting
• Building rapport
• Identifying patients views beliefs and expectations
2) Summarising
• Explaining back to the patient what they have told you
• Allow for correction/development of ideas and understanding
3) Handing over
• Agreeing on doctor’s and patient’s agendas
• Involves negotiating and influencing shared management plan
• Giving ownership and responsibility of management plan to patient
4) Safety netting
• Providing advice on what to do if things get worse
• Could be a follow up, advice, or referral
• For the benefit of both doctor and patient
• Ensures ill patients stay in the medical system
5) Housekeeping
• Looking after yourself as a doctor e.g coffee or going for a walk
• Ensures you can provide a high level of care for every patient you see
What are the 7 stages for the structure of history taking?
• 7 stages of history taking:
1) Presenting complaint (PC)
2) History of presenting complaint (HPC)
3) Past Medial History (PMH)
4) Drug History (DH)
5) Family History (FH)
6) Social history (SH)
7) Systems Inquiry (SE)
How do you start the presenting complaint section (PC) of history taking?
What do you then do?
What is it important to do when doing this?
• The presenting complaint section of history taking should start with an open-ended question
• Examples:
1) Can you tell me a little bit about why you have come in today?
2) Can you tell me what brought you here today?
3) What can I do to help you today?
• It is then important to get a description of symptoms from the patient
• It is important to use the patients’ own words, and get everything down in one sentence e.g cough, sore throat, tummy pain, sore chest
What is it important to establish during history of presenting complaint (HPC)?
What is it important to do during this section?
How can patient conversation be facilitated?
What 2 questions should be constantly be thinking in HPC?
What is a useful 8-part mnemonic for when patients present with pain during the History of presenting complaint (HPC) section?
• During history of presenting complaint, it is important to establish a timeline of events from the first symptom to the time of the interview
• Is it important to allow the patient to speak, and not jump in during this section
• Also important to facilitate the patient giving their account by asking a mix of open and close questions
* Be constantly thinking:
1) What are the possible diagnoses?
2) What else do I need to know to help decide which diagnosis is the correct one?
- Useful 8-part mnemonic for when patients present with pain during the History of presenting complaint (HPC) section:
• S – Site – location of pain
• O – Onset – when the pain started, what is sudden or gradual?
• C – Character – shooting, stabbing, dull ache, throbbing pain
• R – Radiation – see if pain radiates away from source
• A – Associated symptoms – give examples
• T – Timing – pain worse at a particular time? Is it constant or intermittent?
• E – exacerbators/relievers – What makes the pain better/worse
• S – severity – pain on a 1-10 rating
What 4 questions we ask about systemic upset?
What can systemic upset indicate?
• 4 questions we ask about systemic upset:
1) Change in appetite
2) Weight loss
3) Fever – probably means infection
4) Tiredness / lethargy
• Systemic upset could indicate malignancy
HPC renal system.
What can flank/lumbar pain be associated with in the GU system?
What is colicky pain?
What can cause colicky pain in the GU system?
Why might this happen?
• HPC renal system.
• Flank/lumbar pain can be associated with the kidneys
• Colicky pain is usually a sharp, localized gastrointestinal or urinary pain that can arise abruptly, and tends to come and go in spasm like waves
• Colicky pain can be created by tubular structures, such as the ureters which are structures from the kidney to the bladder
• This can be from pelvic floor muscles being damaged during child birth
Describe the following GU terms mean:
• Dys
• Haemat
• Noct
• An
• Oli
• Poly
• Uria
• Dys = pain
• Haemat = blood
• Noct = night
• An = none/absent
• Oli = litte
• Poly = many/lots
• Uria = pertaining to urinary system
What 6 questions should we ask regarding the renal system?
What condition can each question indicate?
• 6 questions should we ask regarding the renal system:
1) “Do you ever have pain passing urine”
• Indicates dysuria
2) “Do you have to get up at night to pass urine”
• Indicates nocturia
3) “Have you noticed any blood in your urine”
• Indicates Haematuria
4) “Are you passing more urine than normal”(Excessive urine output of greater than 2.5-3L in 24 hours)
• Indicates polyuria
5) “Are you passing smaller amounts of urine than normal” (small volumes)
• Indicates Oliguria
6) “Have you stopped passing urine” – RED FLAG
• Indicates Anuria
What are the 2 types of haematuria?
• 2 types of haematuria:
1) Microhaematuria
• Blood isn’t obvious in the urine
• Ask about LMP
2) Macro/frank haematuria
What are 3 potential causes of oliguria and anuria?
• 3 potential causes of oliguria and anuria:
1) Consider obstruction: suprapubic pain with intense desire to micturate
2) Consider hypovolaemia: dry / dehydrated
• Vomiting a lot leading to a loss of fluid
3) Consider AKI (acute kidney injury) / renal failure
• What are blood tests showing?
• What is the estimated glomerular filtration rate> (test that shows how the kidneys are functioning)
What are 8 different urinary symptoms?
• 8 different urinary symptoms:
1) Frequency
2) Flow/stream
3) Incomplete emptying
4) Urgency
5) Terminal dribbling
• Urine dribbles into underwear
6) Hesitancy
• Delay in urinary flow
7) Pain (suprapubic, flank / loin)
8) Incontinence
• Having accidents
What 8 factors should we ask about to get more detail on urinary symptoms?
• 8 factors we ask about to get more detail on urinary symptoms:
1) Onset
2) Duration
3) Severity
4) Course
5) Intermittent or continuous?
6) Precipitating factors
7) Relieving factors
8) Previous episodes
What are 5 different types of incontinence?
• 5 different types of incontinence:
1) Stress
• Result of sphincter weakness
• Small leak of urine when intra-abdominal pressure rises
• E.g. coughing, laughing, sneezing, standing up
2) Urge
• Usual cause is detrusor instability
• Strong desire to void and rush to go
• “Didn’t get there in time”
3) Overflow
• Usually due to outflow obstruction
• Leakage of small amounts
• Distended bladder palpable
4) Neurological
• Different types – depends on cause and accompanying neurological deficits
• E.g. – Distended atonic bladder, with large residual volume (autonomic neuropathy) – Loss of sensation and unexpected lack of control (spinal cord injury)
• Typically painful
5) Mixed
• Several different types at once
10) What are 3 reasons why it is important to ask if a patient has a catheter?
• 3 reasons why It is important to ask if a patient has a catheter
1) They may have different pathologies that led to them getting a catheter
2) The catheters may be causing different pathologies, such as infection or blockage
3) Patient may use it intermittently, so may not have it at the time of the consultation
What are 6 associated symptoms to urinary symptoms?
• 6 associated symptoms to urinary symptoms:
1) Vomiting
2) Fever
3) Malaise
4) Anorexia (symptom of loss of appetite)
5) Weight loss
6) Fatigue / lack of energy
Recap: 16 Key renal system symptoms
• 16 Key renal system symptoms
1) Dysuria
2) Nocturia
3) Haematuria
4) Polyuria
5) Oliguria
6) Anuria
7) Frequency
8) Urgency
9) Incontinence
10) Flow / stream
11) Abdominal pain
12) Hesitancy
13) Terminal dribbling
14) Sense of incomplete emptying
15) Retention
16) Systemic upset / associated symptoms
What are 4 serious/common presentations of renal system conditions?
• 4 serious/common presentations of renal system conditions:
1) UTI, cystitis
• Presents with Dysuria, frequency, urgency, suprapubic discomfort
2) Pyelonephritis
• Pyelonephritis is a type of urinary tract infection where one or both kidneys become infected
• Presents with systemic upset, fever, rigors, vomiting, flank pain
3) Enlarged prostate (Benign Prostatic Hypertrophy, prostate cancer)
• Both present with same symptoms and press on the urethra
• Presents with slow flow, hesitancy, incomplete emptying, dribbling, nocturia
4) Bladder cancer
• Painless frank haematuria
• If the patient isn’t on their period, and there is no pain that is typically associated with infection, we have to run tests to rule out bladder cancer
HPC reproductive system – man.
What are 14 different key HPC symptoms for the reproductive system in men?
• HPC reproductive system – man
• 14 different key HPC symptoms for the reproductive system in men:
1) Urethral discharge
• Amount
• Smell
• Bloody
• Associated symptoms
2) Testicular pain
• Any link to trauma?
• Link to other illness / symptoms (e.g. mumps)
• Speed of onset and severity
• Associated swelling / redness / tenderness / discharge
• Sudden severe testicular pain with associated swelling and redness – suspect testicular torsion
3) Testicular lumps
• Unilateral / bilateral
• Location
• Associated symptoms
• Hard / soft
• Regular / irregular
• Consider testicular cancer, occurs in young men too (mainly between 15 and 49 years of age)
• Unilateral, hard, and craggy are more concerning
• Hydrocoeles are harmless testicular swellings
• Would likely get an ultrasound scan
4) Joint, eye or GI symptoms
• If associated with urethral discharge, consider Reiter’s syndrome
• Reiter’s syndrome, also known as reactive arthritis, is the classic triad of conjunctivitis, urethritis, and arthritis occurring after an infection, particularly those in the urogenital or gastrointestinal tract
5) Rash / ulcers
• Consider herpes / genital warts
6) Human Papilloma Virus
• Genital warts (cauliflower type)
7) Herpes Simplex Virus
• Genital herpes (vesicular rash)
8) Itch
• Associated rash, discharge?
9) Smell
10) Infertility / fertility problems
• >12mths
• Any children with previous partners?
• See earlier:
11) Urinary symptoms
12) Abdominal pain
13) Systemic upset
14) Partner affected
What are 5 serious/common presentations of reproductive system conditions in men?
• 5 serious/common presentations of reproductive system conditions in men:
1) Acute prostatitis
• Presents with pelvic, perineal or scrotal pain, fever, systemic upset
2) Chronic prostatitis
• Presents with chronic pelvic/perineal/scrotal pain and urinary symptoms
3) Urethritis (either STI or UTI)
• Presents with discharge, dysuria, other urinary symptoms
4) Testicular tumour
• Presents with painless hard swelling of body of testis
5) Testicular torsion
• Presents with acutely painful swollen unilateral testicle
HPC reproductive system – woman.
What are 17 different key HPC symptoms for the reproductive system in woman?
• HPC reproductive system – woman
• 17 different key HPC symptoms for the reproductive system in woman:
1) Dyspareunia (painful intercourse)
• Deep
• Superficial
2) Dysmenorrhoea (painful periods)
• When and for how long
3) Menorrhagia (heavy periods)
• Clots
• Flooding
• Are they using double protection for periods?
4) Inter Menstrual Bleeding (IMB) (bleeding between periods)
5) Post-Menopausal Bleeding (PMB) (bleeding after the menopause (occurring after 12 months of amenorrhoea))
6) Post Coital Bleeding (PCB) (bleeding after intercourse)
7) Vaginal dryness
• Common, especially postmenopausal
8) Itch
• Associated rash, discharge?
9) Smell
• E.g. fishy (bacterial vaginosis), offensive
10) Rash
• – E.g. Herpes (vesicular), Genital warts
11) Infertility / fertility problems
• Trying for more than 12 months
12) Urinary symptoms (see earlier)
13) Abdominal / pelvic pain (see earlier); or pain around perineum itself
14) Systemic upset; including fever (see earlier)
15) Partner affected?
16) Possibility of pregnancy
• Ask the patient if they mind doing a pregnancy test
• When was their LMP?
17) Smear history
• Smears can look for HPV
• Now screened for
What 3 pieces of information do we want to know about menstrual history?
• 3 pieces of information do we want to know about menstrual history:
1) Age at menarche (when did periods start?)
• Average age in the UK is 12 years 11 months
• Consider primary amenorrhoea if no period by age 14 years (in the absence of secondary sexual characteristics, such as hair and breast growth), or 16 (if other features are developing normally)
• Secondary amenorrhoea; had periods but now stopped for 6 consecutive months
2) If relevant, age at menopause
• Usually occurs between 45 and 55 years of age; average age is 51 – Menopause before 40 years of age = premature menopause or premature ovarian insufficiency
3) Always establish LMP (last menstrual period)
• How to express this in photo
HPC reproductive system – woman.
What is obstetrics?
What are 7 different key HPC symptoms for obstetrics in woman?
• HPC reproductive system – woman
• Obstetrics is relating to childbirth and the processes associated with it.
• 7 different key HPC symptoms for obstetrics in woman:
1) Para
• Number of times that she has given birth to a foetus with a gestational age of 24 weeks or more
2) Gravida
• Number of times a woman has been pregnant
• Any difficulties getting pregnant; any fertility treatment i.e. If pregnant 3 times, 1 delivery at term, 1 early TOP and 1 early miscarriage = Gravida 3 Para 1 +2
3) Pregnancy complications
4) Mode of delivery
• NVD = Normal Vaginal Delivery
5) Postnatal complications (in self and baby)
6) Menarche (first menstrual cycle)
7) Menopause
What are 4 serious/common presentations of reproductive system conditions in woman?
• 4 serious/common presentations of reproductive system conditions in woman:
1) Endometrial or cervical pathology
• Presents with unexpected bleeding
2) Endometrial cancer
• 10% of cases of PMB (post-menopausal bleeding)
3) Ectopic pregnancy
• Presents with Bleeding in early pregnancy with RIF/LIF pain (left/right iliac fossa)
4) Thrush
• Creamy PV discharge + itch, otherwise well
What 7 topics may we ask about psychosexual history?
• 7 Topics may we ask about psychosexual history (ask about relevant topics):
1) Relationship details
2) Impotence / erectile dysfunction
3) Intercourse and sexual practices
4) Libido
5) Orgasm
6) Associated symptoms
7) Contraception
What are 14 different types of contraception?
• 14 different types of contraception?
1) Male condom
2) Female condom
3) Intra Uterine Device (IUD)
4) Intra Uterine System (IUS)
5) Diaphragm
6) Progesterone Only Pill
7) Combined Oral Contraceptive
8) Implant
9) Injection
10) Patch
11) Sterilisation
12) Calendar rhythm method
13) Coitus interruptus
14) Vaginal hormonal ring
What 8 additional points should we consider for GU system drug history (DH)?
• 8 additional points should we consider for GU system drug history (DH):
1) Long term meds
2) Recent changes
3) Names of contraceptive pills
4) HRT
5) Drugs that cause renal impairment e.g NSAIDs
6) Drugs associated with sexual dysfunction
7) OTC meds (over the counter)
8) NSAIDs
What are 6 questions that may be asked during the Past Medical History (PMH) section of interview?
What is the 10-part mnemonic for PMH?
• Information about previous illnesses during PMH:
1) Have they been to their doctor for anything before?
2) Have they ever been in hospital?
3) Have they had any operations?
4) Have they had any investigations/treatments for other health problems?
5) Establish if problems are on-going / resolves fully / managed by medication etc
6) Establish chronology and document in ordered fashion
• 10-part mnemonic for PMH
1) J - Jaundice
2) A - Anaemia and other haematological conditions
3) M - Myocardial infarct
4) T – Tuberculosis
5) H – Hypertension and heart disease
6) R – Rheumatic fever
7) E – Epilepsy
8) A – Asthma and COPD
9) D – Diabetes
10) S – Stroke
What topics should we ask about in past medical history (PMH) of the GU system?
• Topics we should ask about in past medical history (PMH) of the GU system:
1) HT, DM, vascular disease, inflammatory diseases
2) Any previous GU illness
3) Urinary tract stones
4) Previous STIs
5) Previous Pelvic Inflammatory Disease
6) Previous ectopic pregnancy
7) Previous testicular problems; such as torsion, tumour, undescended testes
8) Recurrent UTIs
9) Renal disease; including ARF, CRF, dialysis and transplantation
10) Previous surgery
11) Neurological disease
12) Cancer / chemo treatment (can affect fertility) and prior malignancy
What are 6 reasons we ensure accurate medication history?
• 6 reasons we ensure accurate medication history:
1) Improves patient safety
2) Reduces medication errors / near misses
3) Reduces missed doses in hospital
4) Reduces delays to treatment
5) Savings to NHS from prevented errors
6) Improves therapeutic outcomes
What are 6 golden rules of medication history taking?
• 6 golden rules of medication history taking:
1) Be structured – methodically collect current meds, allergies and previous adverse drug reactions
2) Engage with the patient whenever possible but find out who knows best about meds – carer?
3) Use more than one source of information to accurately confirm a patient’s medication history.
4) Be alert to use of high-risk medicines (e.g. warfarin, insulin, methotrexate) as accuracy critical in these cases.
• Warfarin can increase haemorrhage risk
• Methotrexate is on a weekly dose, not a daily dose, so a lot of room for error
5) Women of childbearing age – ask about prescribed contraception
6) Are they taking part in any clinical trials?
• Clinical trial medication use/dosage may not appear on medication list
What question can we use to start drug taking history?
What 9 questions might we ask about each drug?
• To start drug taking history, we can ask “Which medicines are currently prescribed for you to take?”
• 9 questions might we ask about each drug:
1) Name of medicine?
2) Do you know what it is for?
3) What is the dose/strength?
4) What is the route?
5) Number of tablets or puffs or dose units taken?
6) Type/Form – device type? E.g spacer, auto inhaler
7) How often do you take this?
8) Any recent changes to dose / frequency?
9) Do you think you have any side effects with any of these medications?
What 8 additional points should we consider for GU system drug history (DH)?
• 8 additional points should we consider for GU system drug history (DH):
1) Long term meds
2) Recent changes
3) Names of contraceptive pills
4) HRT
5) Drugs that cause renal impairment e.g NSAIDs
6) Drugs associated with sexual dysfunction
7) OTC meds
8) NSAIDs
What are 9 other sources of information we can use about a patient’s medicines?
• Other sources of information we can use about a patient’s medicines:
1) Patient or family/friends/carers
2) Patient’s own medicines – can ask to see their medicines/dosette box
3) Repeat prescription slips/other lists – need to make sure its up to date
4) GP surgery staff / letter/ printout
5) Previous hospital notes/letters
6) Community pharmacy
7) Emergency Care Summary (ECS) Scotland only. (called Summary Care Record in England)
8) MAR chart – Medication Administration Records from care homes, prepared by Pharmacy
9) Substance misuse services – e.g. for methadone doses
• Methadone isn’t prescribed by general practise, but by substances misuse services
• Sometimes, dosage isn’t included, so we may have to contact them to get this information
What are 3 questions we may ask concerning allergies?
What else can we do?
What are 3 ways of asking about adverse side-effects?
• 3 questions we may ask concerning allergies:
1) Are you allergic to any medicines?
2) What happened when you had these medicines?
3) Have any medicines caused a rash or difficulty breathing in the past?
• We can also check other sources of information
• 3 ways of asking about adverse side-effects:
1) Have any medicines recently been stopped and if so why?
2) Have you ever had a medicine stopped because the Dr thought it was making you worse?
3) Have you ever stopped a medicine because you felt unwell?
What is intentional non-adherence?
What are 4 reasons for unintentional non-adherence?
• Intentional non-adherence– definite decision to not take medicine(s)
• 4 reasons for unintentional non-adherence:
1) Physical dexterity e.g cant reach medicine
2) Reduced vision
3) Cognitive impairment
4) Poor understanding e.g not being taught to use an inhaler properly
What is the purpose of asking about family history (FH)?
What are 4 questions that may be asked?
What may be useful during this section?
What disease might we want to specifically ask about regarding the CV system?
What degree of relative are we most interested about?
What age range are we looking at?
• Asking about family history may give clues about possible genetic pre-disposition to illness
• 4 questions that may be asked regarding family history:
1) Are your parents still alive?
• If yes – how old are they? Do they have any health problems?
• If no – When did they die? What age were they? What did they die from?
2) Do you have any brothers or sisters? How old are they? Are they well/any illnesses?
3) Do you have any children? How old are they? Are they well/any illnesses?
4) Are there any health problems that run in your family?
• We want to ask if any 1st degree relatives (parents, siblings, children) have a history of cardiovascular disease at a young age
• 1st degree male relative less than 55 years
• 1st degree female relative less than 65 years
• May be useful to draw a family tree
What illnesses should we ask about in particular for GU system family history (FH)?
• Illnesses we should ask about in particular in GU family history (FH):
1) Renal disease/Kidney failure
• Polycystic Kidney Disease and Alport syndrome can be particularly relevant
2) HT, stroke, diabetes, deafness, SAH (sub-arachnoid hemorrhage)
3) GU malignancies
What are the various aspects of social history (SH) asked about?
1) Employment
• Are you working at the moment?
• May I ask what you do?
• What does that involve?
• Have you had any other jobs in the past?
• Has your health impacted your work at all?
• Important to consider occupation exposure e.g asbestos, excessive noise
2) Smoking
• Do you smoke at all?
• Have you ever smoke?
• If stopped, when did you stop?
• Important to calculate pack years – Packs of cigarettes smoked a day x number of years the person has smoked (20 cigarettes per pack)
• E.g 1 pack year is equal to 1 pack of cigarettes a day for a year (1x1)
3) Alcohol
• Do you drink at all?
• If yes – How often do you drink and how much?
• Try convert these to units, and be aware of recommended limits of alcohol consumption
• Men and women advised to not have more than 14 units a week on a regular basis
• Drinking should be spread across 3 or more days if 14 units is consumed regularly in a week
4) Home circumstances
• Who do they live with, or do they live alone?
• Do they live in a house / flat / bungalow, are there stairs?
• DO they have any help at home? How many carers a day
• ADLs (activities of daily living) e.g getting dressed, making food, walking up and down stairs
• This is one of the most important sections, as we want to ensure the patient has access to what they need to live in their home
5) Other questions to consider:
• Exercise/diet
• Do they have any hobbies or interests?
Do they have any pets?
• Do they drive?
What are 5 additional points to consider for GU system social history (SH)?
• 5 additional points to consider for GU system social history (SH):
1) Exposure to chemical carcinogens (bladder cancer)
2) Foreign travel (schistosomiasis)
3) Dehydration during a holiday in a hot climate (impact on kidneys)
4) Non-prescription drugs; effects of cannabis on sexual function (loss of libido)
5) Working in hot environments, e.g. kitchens, and effect on male fertility
What is system enquiry?
What is the purpose of the system enquiry portion of an interview?
What are 7 systems that may be asked about?
What are symptoms we may look for?
• System enquiry is a couple of questions for each remaining system, which acts as a quick screening tool
• Examples of systems and symptoms:
1) CVS – palpitations, syncope (fainting/passing out)
2) RS (respiratory) – cough, mucus, shortness off breath
3) GI – change in bowels, abdominal pain
4) GU (genitourinary) – urinary systems, change in water works, LMP (last menstrual period)
5) Endocrine – lumps in neck, temperature intolerance, changes in weight
6) MS – aches / stiffness in joints / muscles / back
7) CNS – headache, fits, collapses
What are 3 questions we ask to address ideas, concerns, and expectations of the patient?
• Questions to address ideas, concerns, and expectations of patient
1) Do you have any thoughts as to what the problem may be?
2) Is there anything that you are particularly worried it may be?
3) What are you hoping I will be able to do for you today?
What is the purpose of summarising to complete a history taking?
What is important that needs to occur throughout the session?
• Summarising:
• Helps to clarify points
• May highlight questions you haven’t asked or misunderstanding
• Brings up main points of Presenting complaint (PC) and History of presenting complaint (HPC)
• Brings up relevant features in the remainder of history
• Brings up relevant positives/negatives from systems enquiry
• It is important to explain and gain consent for examination as appropriate
