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