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Urological History Taking

History taking

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3K views

Urological History Taking

History taking

Uploaded by

ahmad
Copyright
© © All Rights Reserved
Available Formats
Download as PDF, TXT or read online on Scribd
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Urological History Taking

geekymedics.com/urological-history-taking/

Dr Lewis Potter February 21, 2016

Urological history taking is an


important skill that is often assessed in
the OSCE setting. It’s important to have
a systematic approach to ensure you
don’t miss any key information. The
guide below provides a framework to
take a thorough urological history.

Check out the urological history


taking mark scheme here.

Opening the consultation


Introduce yourself – name/role

Confirm patient details – name/DOB

Explain the need to take a history

Gain consent

Ensure the patient is comfortable

Presenting complaint
It’s important to use open questioning to elicit the patient’s presenting
complaint

“So what’s brought you in today?” or “Tell me about your symptoms”

Allow the patient time to answer, trying not to interrupt or direct the
conversation.

Facilitate the patient to expand on their presenting complaint if required.

“Ok, so tell me more about that” “Can you explain what that pain was like?”

History of presenting complaint

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Pain – if pain is a symptom, clarify the details of the pain using SOCRATES

Site – where is the pain


Onset – duration? / sudden vs gradual?
Character – sharp / dull ache / burning
Radiation – does the pain move anywhere else?
Associations – other symptoms associated with the pain (e.g. fever)
Time course – worsening / improving / fluctuating
Exacerbating / Relieving factors – does anything make the pain worse or better?
Severity – on a scale of 0-10 how severe is the pain?

Key urological symptoms:

Dysuria
Frequency
Urgency
Nocturia
Haematuria
Hesitancy and terminal dribbling
Poor urinary stream
Incontinence
Fever/rigors – suggestive of infection/urosepsis
Nausea/vomiting – often associated with pyelonephritis

If any of the above symptoms are present, gain further details

Onset – When did the symptom start? / Was the onset acute or gradual?

Duration – Minutes / hours / days / weeks / months / years

Severity – i.e. If the symptom was frequency – how many times a day?

Course – Is the symptom worsening, improving, or continuing to fluctuate?

Intermittent or continuous? – Is the symptom always present or does it come and


go?

Precipitating factors – Are there any obvious triggers for the symptom?

Relieving factors – Does anything appear to improve the symptoms?

Previous episodes – Has the patient experienced this symptom previously?

Ideas, Concerns and Expectations


Ideas – what are the patient’s thoughts regarding their symptoms?

Concerns – explore any worries the patient may have regarding their symptoms
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Expectations – gain an understanding of what the patient is hoping to achieve from
the consultation

Summarising
Summarise what the patient has told you about their presenting complaint.

This allows you to check your understanding regarding everything the patient has
told you.

It also allows the patient to correct any inaccurate


information and expand further on certain aspects.

Once you have summarised, ask the patient if there’s anything else that
you’ve overlooked.

Continue to periodically summarise as you move through the rest of the history.

Signposting
Signposting involves explaining to the patient:

What you have covered – “Ok, so we’ve talked about your symptoms and your
concerns regarding them”
What you plan to cover next – “Now I’d like to discuss your past medical history
and your medications”

Past medical history


Urological diseases:

Recurrent urinary tract infections (UTIs)


Incontinence – stress incontinence / functional incontinence
Prostate issues – benign prostatic hypertrophy / prostate cancer
Renal – renal stones / pyelonephritis / chronic renal failure

Other medical conditions – e.g. diabetes predisposes to UTIs

Surgical history – cystoscopy / bladder surgery / renal surgery

Acute hospital admissions? – when and why?

Drug history
Relevant prescribed medication:

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Diuretics – may contribute to nocturia / incontinence
Alpha blockers – commonly used in prostatic enlargement
Nephrotoxic agents – e.g. ACE inhibitor – consider suspension
Antibiotics – those with recurrent UTIs take prophylactic antibiotics

Other regular medications

Over the counter drugs

Herbal remedies

ALLERGIES – ensure to document these clearly

Family history
Urological disease – increased risk of renal stones if parents previously affected

Are parents still in good health? – if deceased sensitively determine age and cause
of death

Social history
Smoking – How many cigarettes a day? How many years have they smoked for?

Alcohol – How many units a week? – type / volume / strength of alcohol

Recreational drug use

Living situation:

House/bungalow? – adaptations / stairs


Who lives with the patient? – is the patient supported at home?
Any carer input? – what level of care do they receive?

Activities of daily living:

Is the patient independent and able to fully care for themselves?


Can they manage self-hygiene/housework/food shopping?

Occupation – increased risk of bladder cancer in those working in specific industries


– industrial dyes/textiles/rubber/plastics/leather tanning

Systemic enquiry

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Systemic enquiry involves performing a brief screen for symptoms in other body
systems.

This may pick up on symptoms the patient failed to mention in the presenting
complaint.

Some of these symptoms may be relevant to the diagnosis (e.g. back pain with renal
stones).

Choosing which symptoms to ask about depends on the presenting complaint and your
level of experience.

Cardiovascular – Chest pain / Palpitations / Dyspnoea / Syncope / Orthopnoea /


Peripheral oedema

Respiratory – Dyspnoea / Cough / Sputum / Wheeze / Haemoptysis / Chest pain

GI – Appetite / Nausea / Vomiting / Indigestion / Dysphagia / Weight loss /


Abdominal pain / Bowel habit

CNS – Vision / Headache / Motor or sensory disturbance/ Loss of consciousness /


Confusion

Musculoskeletal – Bone and joint pain / Muscular pain

Dermatology – Rashes / Skin breaks / Ulcers / Lesions

Closing the consultation


Thank patient

Summarise history

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