Histories Flashcards
1
Q
Gynae Hx Structure
A
- PV bleeding- SOCRATES, character: Postmenopausal? Intermenstrual? Postcoital? how does it feel
- PV pain- SOCRATES, character: dyspareunia- deep or superficial? Dyschezia? Dysuria?
- PV discharge- abnormal discharge? Colour, smell, amount?
- Pregnancy
- Fever, weight loss
-
MOSC
- Menstrual history- cycle, volume, clotting, regularity, dysmenorrhoea, date of LMP, age of menarche
- Obstetrics history- GMC (gravida and parity, miscarriages and TOPs, children)
- Smears and STIs- smear and results, any STIs- treatment for these?
- Contraception- what type? Previous methods?
2
Q
Urology Hx Structure
A
-
Haematuria- SOCRATES
- Site- Where is blood, when do you notice it? During stream? Only on passing urine?
- Onset- when did it start
- Character/colour- is it red? Pink?
- Radiation
- Associated symptoms
- Timing- how has it changed over time?
- Exacerbating factors, anything make it better
- Severity- how many episodes? Happened before? How often?
- Fever
- Dysuria- pain on going to the toilet
- Voiding symptoms- obstructive: Hesitancy, Dribbling, Poor stream/flow
- Storage symptoms (FUN)- irritative: Frequency, Urgency, Nocturia
- Abdominal pain/back pain?
3
Q
Breast Hx Structure
A
- SOCRATES
- Nipple discharge- colour, amount, blood?
- Nipple changes- inversion, discolouration
- Skin changes- eczema, erythema, dimpling
- Axillary lymphadenopathy
- Pain
- Trauma to breast
- Previous breast cancer? Lumps?
- RFs for breast cancer: smoking, early menarche, late menopause, HRT
4
Q
Testicular/Groin Swelling/Lumps
A
- Pain
- Recent trauma
-
Lumps or swellings- SOCRATES
- Site
- Onset
- Character
- Radiation
- Associated symptoms
- Time course
- Exacterbating/relieving factors
- Severity
- Gynaecomastia
- Sexual dysfunction
-
STIs- penile discharge, pain, dysuria, itching
- STIs or history of STIs
- RFs for testicular cancer: surgery in past due to Maldescent, infertility, FHx of testicular cancer
5
Q
Infertility
A
PC, HPCx
- How long trying to conceive
- Frequency of UPSI? Confirm it is vaginal sex
- Contraception- when was this stopped
- Anyone have any problems during sex- anxiety, worries?
MOSC:
- Menstrual history- cycle, regularity, volume, LMP, duration of period, menarche, dysmenorrhea? Menorrhagia?
- Obstetrics- GMC- previous pregnancies, miscarriages and terminations, children? Including children from previous marriages?
- Smears and STIs- date of last smear and result, STI history
- Contraception- when was this stopped, any other methods
RoS: 4 Ps- Pain, PV discharge, Pregnancy, PV bleeding
- PCOS- hirsutism, acne, bloating
- Thyroid- weight change, mood change, temperature insensitivity
- Prolactinoma- nipple discharge, breast changes, visual symptoms
6
Q
Counselling points/Advice for infertility
A
Infertility affects around 1 in 7 couples
Around 84% of couples who have regular sex will conceive within 1 year, 92% within 2 years
Counselling points:
- Folic acid
- Aim for BMI 20-25
- Regular sexual intercourse every 2-3 days
- Smoking/drinking advice
7
Q
Sexual Hx
A
PC/HPCx
RoS:
- Pain- anogenital, pelvic, dyspareunia
- PV Discharge
- PV bleeding
- Pregnancy
- Dysuria
- Swellings/growths/ulcers/skin changes
- Weight loss
ICE and summarise
Partners
- Last time of sexual contact?
- Safeguarding- was it consensual
-
Current partner and recent partners in last 3 months?
- Demographics- where are they from?
- Regular or casual? - sex with men, women or both?
- Barrier methods (Condom) or unprotected?
- Type of sex?- vaginal/oral/anal- giving or receiving
-
High risk encounters
- Partners from abroad?
- Drug use during sex?
- Paid for/been paid for sex
Women- MOSC:
- Menstrual
- Obstetrics
- Sexual- n/a
- Contraception + Smears + STIs
PMHx
- Previous STIs and tests- results of these
- HIV and hepatitis B/C status
- Vaccines
MHx
- Allergies
- Regular meds
SHx- LOST
- Living
- Occupation
- Smoking, alcohol, recreational drug taking
- Travel
8
Q
Menopause Counselling- pharmacological and non-pharmacological
A
Brief Hx:
PC/HPCx
ICE- how it is affecting them
Symptoms of menopause:
-
Menstrual Hx (cycle, regularity, any IMB, LMP?, heaviness, any clots?)
- Change in length of periods? (irregular periods) Abnormal bleeding?
- Vasomotor- hot flushes, night sweats
- Urogenital- vaginal dryness and atrophy, urinary frequency
- Psychological- anxiety and depression? Memory problems, reduced libido, insomnia
- Longer term- osteoporosis?
PMHx- migraine with aura? (cannot take oral HRT) hysterectomy?
….
ICE
- Ideas- “Have you heard of HRT?” “What do you already know?”
- Concerns- “Is there anything that worries you about HRT?”
- Expectations- “What were you hoping HRT might be able to do for you?” “What were you hoping we’d discuss today?”
How much information do you want me to give you today
Lifestyle modifications
- Regular exercise, weight loss, reducing stress- help with hot flushes and cognitive symptoms
- Also maintaining good sleep hygiene, avoiding late-night exercise, and trying to relax
- If needed, CBT- anxiety, low mood, hot flushes, night sweats
Pharmacological:
Non-hormonal
- SSRI/SNRI e.g. fluoxetine/citalopram/venlafaxine- vasomotor symptoms. Also anxiety and depression
- Vaginal lubricant- vaginal dryness
- Psychological symptoms- CBT, self-help groups, antidepressants
Hormonal (HRT- oestrogen +/- progesterone)
- Women with uterus- combined HRT
- Women without uterus- oestrogen only
9
Q
HRT counselling
A
What is HRT, How does it work?
- Treatment for menopause-related symptoms
- Restores the low levels of hormones that occur as a result of menopause (oestrogen +/- progesterone)
- Menopause is when a woman stops having periods and no longer able to get pregnant naturally
- Ovaries stop producing eggs → less oestrogen and progesterone
- → Symptoms such as hot flushes, weak bones, vaginal dryness
- Symptoms are extremely common, severity and duration varies between women. Symptoms may resolve in 2-5 years
Who can take it?
- For treatment of menopausal symptoms
- Those with premature ovarian insufficiency (symptoms <40 years old)- taken until age of natural menopause (around 51 years old), even if asymptomatic
How is it taken (route)?
It can be taken in several ways depending on preference and symptoms
Can be taken orally, patches or gels, and also can have implants
- Oral (tablets)- most common way
- Increased risk of DVT/VTE compared to transdermal
- Transdermal (patches or gel)
- Woman prefers the route
- GI side effects with oral e.g. nausea
- Hx or risk of VTE- does not increase risk of VTE compared to oral
- Hx of migraine with aura
- Implants such as Mirena coil can also be used to give local progesterone to endometrium
- Added benefit of contraception
What HRT regimes are available?- oestrogen only vs combined
If local symptoms e.g. vaginal dryness, give topical treatment like oestrogen cream or tablets
If systemic symptoms, give HRT (systemic treatment)
Combined (oestrogen and progestogen)
- Recommended for women with a uterus
- If perimenopausal/LMP in last 12 monthsà cyclical/sequential combined HRT e.g. monthly or 3 monthly (end of every cycle or every 13 weeks)
- If postmenopausal/LMP >12 monthsà continuous combined HRT
Oestrogen only- unopposed oestrogen therapy
- Recommended for women without a uterus (hysterectomy)- do not require endometrial protection provided by progestogens
Benefits
Treat symptoms of menopause:
- Reduces vasomotor symptoms- hot flushes
- Improved mood and depressive symptoms
- Improve vaginal dryness and sexual function. Improve urinary urgency
- Prevents thinning of bones and therefore reduce risk of fractures
- Reduce risk of cardiovascular disease e.g. high blood pressure and heart attacks
Disadvantages
- If contains oestrogen: breast tenderness, leg cramps, nausea, headaches
- If contains progesterone: breast tenderness, backache, low mood, pelvic pain
- Breakthrough bleeding is common in first 3-6 months with continuous combined HRT
Risks
- VTE- only with oral route. No risk with transdermal
- Stroke- small increase with oral. No risk with transdermal
- Breast cancer- increased risk with combined HRT (2 hormones, 2 breasts), related to treatment duration. Does not affect risk of dying from breast cancer. No increase with oestrogen only
- Endometrial cancer- increased with oestrogen only for those with a uterus (reduce risk by adding progesterone)
Contraindications
- Current, past or suspected breast cancer
- Undiagnosed vaginal bleeding
- Untreated endometrial hyperplasia
- VTE- unless on anticoagulation
- Untreated hypertension
10
Q
Palliative Hx
A
PC/HPCx
SOCRATES
RoS:
- Breathlessness
- Constipation
- Diarrhoea
- Anxiety
- Nausea and vomiting
- Anorexia/weight loss
- Loss of appetite
- Dysuria, frequency, hesitancy
PMH
MHx
FHx
SHx:
- Home circumstances
- Occupation
- Hobbies
- Smoking, alcohol, recreational drugs
- Coping with ADLs
- Have a DNCAPR? Living will/advanced directive. LPOA. Advanced statement
Psych
- How would they describe their mood?
- Previous episodes of mental health- treated?
- Depression screen- anhedonia, anergia, low mood
Spiritual
What is important in their life currently? Religious affiliation? Where do they find strength
11
Q
Back Pain/Orthopaedics
A
SOCRATES
RoS:
- Previous malignancy
- Weakness? Sensory changes?
- Saddle anaesthesia, incontinence- bladder and bowel
- Sciatica
- Worse on coughing, lying down
- Hx of Trauma
- Weight loss, fever, night sweats- systemically unwell
12
Q
Joint Pain/Rheumatology
A
SOCRATES
RoS:
- Swelling, redness
- Infections
- Uveitis/iritis (e.g. uveitis associated with ankylosing spondylitis)
- Dysuria- reactive arthritis
- Conjunctivitis
- Fever, weight loss
13
Q
Clinically Assisted Hydration + Nutrition Counselling
A
CAN- Includes IV feeding, feeding by NG tube, and PEG and RIG feeding tubes through the abdominal wall. These means can also provide fluids necessary to keep patients hydrated
Benefits:
- Can improve sedation and myoclonus- some symptom relief
- Will not change the fact that the patient is dying
- As people enter “dying phase”- believe people do not need as much fluid
- When a person is dying, body slows down, bodies’ need for food and drink changes
- A health person can lives for months without food but only days without hydration
Disadvantages:
- May not make difference to patient
- Can make other symptoms worse- breathlessness, secretions
- May affect other fluid retention issues- heart failure, ascites, pulmonary oedema
- Burdensome to deliver treatment- drips, needles…
14
Q
Syringe Driver Counselling
A
What is a syringe driver:
- Small, battery-powered pump that delivered medication at a constant rate throughout the night and day
- Medicines put in a syringe and driver pushes them through a small plastic tube and into your body
- Tube is inserted using a thin needle, which is then removed. It is usually inserted just under the skin on your arm, leg, abdomen
- Sometimes it is called a continuous subcutaneous infusion
How long can they be left in:
- Depends on the symptoms- may only be few days or weeks- nurse will keep checking to see if it’s working properly
- Site is not painful, leaking red, or swollen
- Can replace needle in different part of body for few days
Why are they used:
- Difficult to swallow tablets or liquids
- If symptoms cannot be managed with tablets or injections
- Nausea and vomiting
- Need >2 injections of medications within 24 hours
- If body cannot absorb medicine properly e.g. bowel obstruction
They are often used in the last few weeks and days of life but they are not only used at this stage
Can be useful for managing symptoms at any stage
Medicines to treat symptoms:
- Pain- morphine
- Nausea and vomiting- Cyclizine, haloperidol, metoclopramide, levomepromazine
- Agitation- midazolam
- Too much fluid in the throat and lungs (respiratory secretions)- hyoscine hydrobromide, hyoscine butylbromide, glycopyrronium
- Breathlessness- morphine
Common worries:
- Means that they will die soon- not necessarily true, syringe drivers can be used at any stage. Some people just use them for a short time to manage symptoms. Often used at end of life as person is unable to swallow medicines, or body stops being able to absorb them properly- syringe driver is often best way to give medicines
- Makes them die sooner- no evidence for this. They are used often at end of life because easiest ways to give someone medicines they need to feel comfortable
15
Q
Ix and management for Haematuria
A
Testing:
- Urine dipstick/Urinalysis (UTI)
- DRE (BPH, prostate cancer)
- Bloods- FBC, U&Es, PSA coagulation
- Abdominal exam→ renal masses
- Male genitalia exam→ varicocele (can be sign of malignancy)
- Imaging: renal tract ultrasound, CT kidneys, ureters, bladder (CTKUB)
- Cystoscopy
- Renal biopsy
Urgent 2WW if:
Aged >45 and:
- Visible haematuria w/o UTI or
- Visible haematuria that persists or recurs after successful treatment of UTI
Aged >60 with unexplained nonvisible haematuria and either:
- Dysuria or
- Raised WCC on blood test
