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    Urological History Taking

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    ayuni
    This document provides a framework for taking a thorough urological patient history. It outlines key areas to cover including the patient's presenting complaint, history of present symptoms, past medical history, medications, family history, social history, and a brief systemic review of other body systems. The goal is to gain a full understanding of the patient's condition through open-ended questions, active listening, periodic summarization to check understanding, and signposting to inform the patient about the structure of the consultation.

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    © All Rights Reserved
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    Urological History Taking

    Uploaded by

    ayuni
    87 views6 pages
    This document provides a framework for taking a thorough urological patient history. It outlines key areas to cover including the patient's presenting complaint, history of present symptoms, past medical history, medications, family history, social history, and a brief systemic review of other body systems. The goal is to gain a full understanding of the patient's condition through open-ended questions, active listening, periodic summarization to check understanding, and signposting to inform the patient about the structure of the consultation.

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    Geekymedics.com-Urological History Taking

    Original Title

    Geekymedics.com-Urological History Taking

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    This document provides a framework for taking a thorough urological patient history. It outlines key areas to cover including the patient's presenting complaint, history of present symptoms, past medical history, medications, family history, social history, and a brief systemic review of other body systems. The goal is to gain a full understanding of the patient's condition through open-ended questions, active listening, periodic summarization to check understanding, and signposting to inform the patient about the structure of the consultation.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    87 views6 pages

    Urological History Taking

    Uploaded by

    ayuni
    This document provides a framework for taking a thorough urological patient history. It outlines key areas to cover including the patient's presenting complaint, history of present symptoms, past medical history, medications, family history, social history, and a brief systemic review of other body systems. The goal is to gain a full understanding of the patient's condition through open-ended questions, active listening, periodic summarization to check understanding, and signposting to inform the patient about the structure of the consultation.

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    You are on page 1of 6

    Urological history taking

    geekymedics.com/urological-history-taking/

    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.

    HPC
    Past Medical Hx
    Drug Hx
    Family Hx
    Social Hx
    Systemic enquiry
    Interactive mark scheme
    Mark Scheme (PDF)

    Opening the consultation


    Introduce yourself – name/role

    Confirm patient details – name/DOB

    1/6
    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


    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

    2/6
    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

    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”
    3/6
    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:

    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

    4/6
    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
    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

    5/6
    Closing the consultation
    Thank patient

    Summarise history

    Assessment
    0%

    6/6

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