23-01-23 – History Taking – GU (Watch lecture for practise questions) Flashcards

Question

What 3 pieces of information do we want to know about menstrual history?

Answer 1

• 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

Answer 2

• 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

Answer 3

• 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

Answer 4

• 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

Answer 5

• 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

Answer 6

• 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

Answer 7

• 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

Answer 8

• 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

Answer 9

• 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

Answer 10

• 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

Answer 11

• 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?

Answer 12

• 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

Answer 13

• 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

Answer 14

• 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?

Answer 15

• 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

Answer 16

• 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

Answer 17

• 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

Answer 18

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?

Answer 19

• 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

Answer 20

• 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

Answer 21

• 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?

Answer 22

• 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

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23-01-23 – History Taking – GU (Watch lecture for practise questions) Flashcards

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