Sunteți pe pagina 1din 192

RESPIRATORY HISTORY TAKING

Posted by Dr Lewis Potter | History taking

Table of Contents
We’d really appreciate if you could leave us a rating
Respiratory 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 respiratory history. Check out the respiratory history mark schemehere.

HPC
PAST MEDICAL HX
DRUG HX
FAMILY HX
SOCIAL HX
SYSTEMIC ENQUIRY
INTERACTIVE MARK SCHEME
MARK SCHEME (PDF)

Introduction
Introduce yourself – name/role
1
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


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

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

Severity – e.g. if the symptom is shortness of breath – are they able to talk in full sentences?

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 e.g. an inhaler

Associated features – are there other symptoms that appear associated e.g. fever/malaise

Previous episodes – has the patient experienced this symptom previously?

2
Key respiratory symptoms:

 Dyspnoea – Only on exertion or at rest? / Determine severity


 Cough – Dry vs productive / Sputum (volume, colour, consistency)
 Wheeze – Time of day / Triggers
 Haemoptysis – Volume
 Chest pain – Site / Radiation / Character
 Systemic symptoms – Fever / Night sweats / Weight loss
If any of these symptoms are present, gather further details as shown above (Onset / Duration / Course /
Severity / Precipitating factors / Relieving factors / Associated features / Previous episodes)

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

 Site – where is the pain


 Onset – when did it start? / sudden vs gradual?
 Character – sharp / dull ache / burning
 Radiation – does the pain move anywhere else?
 Associations – other symptoms associated with the pain
 Time course – worsening / improving / fluctuating / time of day dependent
 Exacerbating / Relieving factors – does anything make the pain worse or better?
 Severity – on a scale of 0-10, how severe is the pain?

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.
3
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


Respiratory conditions – asthma / pneumonia / COPD / pulmonary embolism / malignancy / tuberculosis

Other medical co-morbidities – cardiovascular disease / neuromuscular disease / malignancy

Surgical history

Acute hospital admissions / ITU admissions?

Drug history
Regular medications – often provide useful clues as to patients past medical history

 Inhalers – preventer / reliever


 Steroids

 Diuretics

Antibiotics

Over the counter drugs / herbal remedies?

Home oxygen?

Medications with respiratory side effects:

4
 Beta-Blockers / NSAIDS – bronchoconstriction
 ACE inhibitors – dry cough
 Cytotoxic agents – interstitial lung disease
 Oestrogen – e.g. contraceptive pill / HRT – increased risk of PE
 Amiodarone / Methotrexate – pleural effusions / interstitial lung disease

ALLERGIES – document these clearly

Family history
Respiratory disease? – asthma / atopy / lung cancer / cystic fibrosis

Recent contact with others who were unwell? – viral infections / pneumonia / TB

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

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

Recreational drug use – e.g. Cannabis (increased risk of lung cancer)

Living situation:

 House / Flat – stairs / adaptations / home oxygen


 Who lives with the patient? – important when considering discharge from hospital
 Any carer input? – what level of care do they receive?

Activities of daily living:

 Is the patient independent / able to fully care for themselves?

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

5
Occupation:

 Shipyard / Construction / Plumber – Asbestos


 Miners – Pneumoconiosis
 Farmer – Allergic extrinsic alveolitis

Hobbies – Bird fancier – Allergic extrinsic alveolitis

Travel history
High-risk areas for tuberculosis (TB)?

Recent long-haul flights? – pulmonary embolism

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. calf pain in pulmonary embolism).

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

Urinary – Volume of urine passed / Frequency / Dysuria / Urgency / Incontinence

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

6
Musculoskeletal – Bone and joint pain / Muscular pain

Dermatology – Rashes / Skin breaks / Ulcers / Lesions

7
GASTROINTESTINAL HISTORY TAKING
8
Posted by Dr Lewis Potter | History taking

Table of Contents
We’d really appreciate if you could leave us a rating
Gastrointestinal history taking requires a systematic approach to ensure you don’t miss anything
important. This guide structures the history in parallel with the structure of the GI system, beginning at the
mouth and working downwards. Over time you will stop using this approach and only ask a smaller more
focused subset of these questions which are relevant to the given presenting complaint, but it takes time to
become competent at this, so this is a good starting point. Check out the gastrointestinal OSCE mark
scheme here.

HPC
PAST MEDICAL HX
DRUG HX
FAMILY HX
SOCIAL HX
SYSTEMIC ENQUIRY
INTERACTIVE MARK SCHEME
MARK SCHEME (PDF)

9
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


The following questions should be asked for each symptom the patient is experiencing.

Onset – when did the symptom start? / was the onset acute or gradual?

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

Severity – e.g. if symptom is weight loss – how much weight loss?

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 e.g. increasing dietary intake
10
Associated features – are there other symptoms that appear associated (e.g. fever/malaise)

Previous episodes – has the patient experienced this symptom previously?

Key gastrointestinal symptoms:

 Dysphagia / odynophagia – solids vs liquids


 Nausea / vomiting – triggers/ colour of vomit / haematemesis
 Reduced appetite / weight loss

 Gastroesophageal reflux

 Abdominal pain – SOCRATES


 Abdominal distension

 Altered bowel habit – constipation / diarrhoea / fresh blood / malaena


 Systemic symptoms – jaundice / fever / malaise / fatigue

Upper gastrointestinal tract symptoms


Mouth – Pain / Ulcers / Growths

Dysphagia – Onset / Progression / Solids and/or liquids

Odynophagia – pain on swallowing – oesophageal candidiasis

Progressive dysphagia (difficulty swallowing solids at first, then eventually difficulty with liquids) suggests the
presence of a malignant stricture. Especially in elderly patients with associated weight loss and iron deficiency
anaemia.

Nausea and vomiting


Frequency and volume – high frequency and volume increases risk of dehydration

Projectile vomiting – obstruction

What does the vomit look like?

 Undigested food – pharyngeal pouch / achalasia / oesophageal stricture


 Non-bilious vomit – pyloric obstruction (i.e. pyloric stenosis)
 Bilious vomit/ faecal matter – lower GI obstruction (i.e. severe constipation)

Haematemesis
Colour:

11
 Fresh red blood – undigested – acute bleed – Mallory Weiss tear / oesophageal variceal rupture
 Coffee ground – digested – bleeding peptic/ duodenal ulcer
Preceded by forceful retching? – Mallory Weiss tear

Anorexia/weight loss
How much weight over how long? – always suspect malignancy – especially in the elderly

Decreased appetite – may suggest malignancy, or in younger patients possibly anorexia nervosa

Abdominal pain
Is pain localised to a specific area of the abdomen?

 Right iliac fossa – appendicitis / Crohn’s disease


 Left iliac fossa – diverticulitis
 Epigastric – gastritis/oesophagitis
 Right upper quadrant – cholecystitis/hepatitis
 Flank – pyelonephritis
 Suprapubic – cystitis

Is the pain intermittent or continuous?

 Intermittent – e.g. renal colic/biliary colic/bowel obstruction


 Continuous – e.g. cystitis/peritonitis

Use SOCRATES to gain more details about the pain.

Bloating
Common causes of abdominal distension:

 Fat – obesity
 Flatus – paralytic ileus/obstruction
 Faeces – constipation
 Fluid – ascites
 Fetus – pregnancy

Altered bowel habit


Diarrhoea

Consistency – how formed is it? (Bristol stool chart)


12
Mucous – Inflammatory bowel disease (IBD) / Irritable bowel syndrome (IBS)

Blood – Fresh red blood (anal fissure/haemorrhoids/IBD). Melaena (upper gastrointestinal bleed)

Urgency– IBD/IBS/gastroenteritis

Recent antibiotics? – C. Difficile

Recent suspect food? – food poisoning

Laxative use?

Constipation

Duration of constipation

Absolute constipation? – not passing flatus – obstruction

Colour of the stool

Black (Melaena) – peptic ulcer / duodenal ulcer / malignancy

Fresh red blood – anal fissure / haemorrhoids / IBD / polyp / lower GI malignancy

Pale (steatorrhoea) – biliary obstruction (gallstones / malignancy)

Jaundice
Yellowing of the skin and sclera

Dark urine

Causes of jaundice:

 Infectious – hepatitis B and C / malaria


 Malignancy – pancreatic cancer / cholangiocarcinoma
 Alcoholic liver disease
 Autoimmune – autoimmune hepatitis / primary sclerosing cholangitis
 Congenital – Gilbert’s syndrome (benign)

13
Pain
If pain is a symptom, clarify the details of the pain using SOCRATES

 Site – where is the pain


 Onset – when did it start? / sudden vs gradual?
 Character – sharp / dull ache / burning
 Radiation – does the pain move anywhere else?
 Associations – other symptoms associated with the pain
 Time course – worsening / improving / fluctuating / time of day dependent
 Exacerbating / Relieving factors – does anything make the pain worse or better?
 Severity – on a scale of 0-10, how severe is the pain?
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”
 What you plan to cover next – “Now I’d like to discuss your past medical history”

Past medical history


Gastrointestinal disease – inflammatory bowel disease (IBD) / irritable bowel syndrome / malignancy /
gastroesophageal reflux (GORD)

Other medical conditions


14
Surgical history – e.g. appendectomy / colectomy / c-section

Any recent hospital admissions? – when and why?

Travel history
Local food? – e.g. salmonella poisoning

Insect bites? – malaria

Contact with dirty water? – campylobacter / shigella / giardia

Drug history
Gastrointestinal medications:

 Laxatives

 Loperamide

 Proton pump inhibitors

 H2 receptor antagonists

 Sodium alginate/calcium carbonate e.g. Gaviscon

Regular medications – NSAIDS / Steroids /Bisphosphonates – (Gastroduodenal erosions)

Over the counter drugs – NSAIDS / laxatives

Contraception? – consider gynaecological causes of abdominal pain –ectopic pregnancy / miscarriage

ALLERGIES?

15
Family history
Gastrointestinal disease – malignancy / IBD / GORD

Hereditary bowel conditions – HNPCC / FAP

Other significant medical conditions

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

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

Recreational drug use – IV drug use is a risk factor for hepatitis

Sexual history – important if considering blood-borne viruses – e.g. hepatitis

Diet:

 Lack of fibre – constipation


 Gluten – coeliac disease
 Fatty foods – may be associated with upper abdominal pain – cholecystitis

Living situation:

 House / flat – stairs / adaptations


 Who lives with the patient? – important when considering discharging home from the hospital
 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?

 Is the illness interfering with the patient’s ability to do the above?

Occupation

16
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. erythema nodosum in inflammatory bowel
disease).

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

Urinary – Volume of urine passed / Frequency / Dysuria / Urgency / Incontinence

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

Musculoskeletal – Bone and joint pain / Muscular pain

Dermatology – Rashes / Skin breaks / Ulcers / Lesions

17
CHEST PAIN HISTORY
Posted by Dr Lewis Potter | History taking

Table of Contents
We’d really appreciate if you could leave us a rating
Taking a comprehensive chest pain history 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 chest pain history. Check out the chest pain history OSCE mark
scheme here.

HPC
PAST MEDICAL HX
DRUG HX
FAMILY HX
SOCIAL HX
SYSTEMIC ENQUIRY
INTERACTIVE MARK SCHEME
MARK SCHEME (PDF)

Opening the consultation


18
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 chest pain was like?”

History of presenting complaint


Gain further details about the chest pain using SOCRATES

Site – where is the pain (e.g. central chest)

Onset:

 Duration of pain (important when considering angina vs acute coronary syndrome)

 Did it come on suddenly or has it been gradually building?

19
 What was the patient doing at the time of onset? (exertional / at rest)

Character:

 Aching/crushing – typical of acute coronary syndrome (ACS)


 Sharp pain that’s worse on inspiration (pleuritic) – pulmonary embolus/pneumothorax

Radiation:

 Does the pain move anywhere else?

 Left arm and jaw is typical of ACS

 Radiation through to the back is associated with aortic dissection

Associated symptoms:

 Dyspnoea – exertional? / orthopnea? / paroxysmal nocturnal dyspnoea?


 Sweating / clamminess / nausea – associated with ACS
 Cough – duration? / productive of sputum? (pneumonia) / haemoptysis? (PE)
 Palpitations – ask patient to tap out the rhythm
 Syncope / dizziness – postural? / exertional? / random?
 Oedema – peripheral oedema (e.g. lower limbs)
 Fever – pericarditis / costochondritis / pneumonia

Time course:

 Duration – minutes / hours / days / weeks


 Worsening / improving / fluctuating

Exacerbating/relieving factors:

 Does anything make the pain worse?

 Inspiration (PE / pneumothorax / pneumonia)


 Exertion (ACS / PE / pneumothorax / pneumonia)
 Lying flat (pericarditis)
20
 Does anything make the pain better?

 GTN spray (ACS or oesophageal spasm)


 Leaning forward (pericarditis)

Severity – on a scale of 0-10 how severe is the pain?

Has the patient had chest pain like this before?

 If the patient has angina, is this pain similar or different?

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”
 What you plan to cover next – “Now I’d like to discuss your past medical history and your medications”

21
Past medical history
Cardiovascular disease:

 Angina

 Myocardial infarction – bypass grafts / stents


 Hypertension

 Hyperlipidaemia

 Aortic aneurysm / dissection

Respiratory disease:

 Pneumonia

 Pneumothorax

 Pulmonary embolus

Gastrointestinal disease:

 Gastro-oesophageal reflux

 Oesophageal spasm

Other medical conditions

Surgical history – bypass graft / stents / valve replacements

Acute hospital admissions – when and why?

Drug history
Regular prescribed medication

22
 Antiplatelets or anticoagulants

 GTN spray

Contraceptive pill – increased risk of thromboembolic disease (e.g. PE)

Over the counter drugs

Herbal remedies

ALLERGIES – ensure to document these clearly

Family history
Cardiovascular disease at a young age – myocardial infarction / hypertension / thrombophilia

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 – e.g. Cocaine – coronary artery vasospasm

Diet – obesity/fat and salt intake – cardiovascular risk factors

Exercise – baseline level of patient’s day to day activity

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?

23
Activities of daily living:

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

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

Occupation – sedentary jobs increase cardiovascular risk – e.g. lorry driver

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. fever in pericarditis).

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

Urinary – Volume of urine passed / Frequency / Dysuria / Urgency / Incontinence

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


24
Thank patient

Summarise history

Differential diagnoses of chest pain


Below is a selection of differential diagnoses that can present with chest pain, with included typical
presenting patterns.

Cardiovascular
Acute coronary syndrome:

 Central crushing chest pain

 Radiating to left arm/jaw

 Duration of more than 20 minutes

 Associated with sweating/clamminess/nausea/shortness of breath

 Symptoms are often worsened by exertion and improved with GTN spray

Stable angina:

 Central chest pain

 Radiating to left arm/jaw

 Duration less than 20 minutes with full resolution

 Often triggered by exertion and resolved with GTN spray/rest

 Associated with shortness of breath

Pericarditis:

 Central chest pain

 Worsened by lying flat and improved by leaning forwards

25
 Patient may have had multiple episodes in the past

Aortic dissection:

 Central chest / abdominal pain

 Radiating through to the back

 “Tearing” in nature

 May have associated syncope/dizziness due to haemodynamic instability

Respiratory
Pneumonia:

 Sharp chest pain worsened by inspiration (pleuritic)

 Associated cough, shortness of breath, fever and malaise

Spontaneous pneumothorax:

 Sudden onset sharp chest pain

 Pleuritic in nature

 Shortness of breath

Pulmonary embolism:

 Sudden onset chest pain

 Shortness of breath

 Haemoptysis (rare)

Gastrointestinal
Gastro-oesophageal reflux:

 Epigastric / chest pain

26
 Burning in nature

 Worsened by lying flat

Oesophageal spasm:

 Epigastric / central chest pain

 Relieved by GTN spray (hence can be confused with ACS)


 No associated shortness of breath

27
UROLOGICAL HISTORY TAKING
Posted by Dr Lewis Potter | History taking

Table of Contents
We’d really appreciate if you could leave us a rating
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
28
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


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:

29
 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

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.

30
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:

 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

31
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?

32
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

33
DERMATOLOGICAL HISTORY TAKING – OSCE GUIDE
Posted by Jacob Michie | Dermatology, History taking

Table of Contents
We’d really appreciate if you could leave us a rating
Taking a dermatological history is an important skill that is often assessed in the OSCE setting. It usually
involves taking a history of a skin lesion or rash, and 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 history of
any skin problem. Check out the dermatology history taking OSCE mark scheme here.

HPC
PAST MEDICAL HX
DRUG HX
FAMILY HX
SOCIAL HX
SYSTEMIC ENQUIRY
INTERACTIVE MARK SCHEME
MARK SCHEME (PDF)

Introduction
Introduce yourself – name/role

Confirm patient details – name/DOB

34
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 the rash” “Can you explain what that pain was like?”

History of presenting complaint


Onset:

 When did the skin problem start?

 Was the onset acute or gradual?

Course – has the rash/skin lesion changed over time?

Intermittent or continuous – is the skin problem always present or does it come and go?

Duration of the symptom if intermittent – minutes/hours/days/weeks/months/years

Location/distribution:

 Where is the skin problem?

35
 Number of lesions?

 Is it spreading?

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

Relieving factors – does anything appear to improve the symptoms (e.g. steroid cream)?

Associated features – are there other symptoms that appear associated (e.g. fever/malaise)?

Previous episodes – has the patient experienced this problem previously?

 When?

 How long for?

 Was it the same or different than the current episode?

Previous or current treatment for this skin problem (did it work?):

 Prescribed medication

 Over the counter medication

Contact history – has the patient been in contact with an infectious skin problem (e.g. chickenpox)?

Sun exposure (including sunbed use)

 Important when considering skin cancer in the differential diagnosis

 Ask the patient about how their skin reacts to sun exposure to help determine their skin type (Fitzpatrick
scale)

Key dermatology symptoms:


 Pain
 Itch
 Bleeding
36
 Discharge
 Blistering
 Systemic symptoms – fever / malaise / weight loss / arthralgia
If any of these symptoms are present, gather further details as shown above (Onset / Duration / Course /
Severity / Precipitating factors / Relieving factors / Associated features / Previous episodes)

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

 Site – where is the pain?


 Onset – when did it start? / sudden vs gradual?
 Character – sharp / dull ache / burning
 Radiation – does the pain move anywhere else?
 Associations – other symptoms associated with the pain?
 Time course – worsening / improving / fluctuating / time of day dependent
 Exacerbating / Relieving factors – does anything make the pain worse or better?
 Severity – on a scale of 0-10, how severe is the pain?

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”
 What you plan to cover next – “Now I’d like to discuss your past medical history and your medications”

37
Past medical history
Skin disease:

 Skin cancer

 Atopy – eczema / hay fever / asthma

 Other dermatological conditions

Other medical conditions – many of which can have dermatological manifestations

 Diabetes – acanthosis nigricans / scleroderma diabeticorum / necrobiosis lipoidica diabeticorum


 Inflammatory bowel disease – pyoderma gangrenosum / erythema nodosum

Drug history
Skin treatments – creams / ointments / UV therapy / antibiotics / biologics

Regular medication – including length of treatment (paying particular attention to those started around
the time of the skin problem)

Antibiotics

Over the counter drugs

Cosmetics

Herbal remedies

ALLERGIES (a common cause of rashes) – ensure to document these clearly

38
Family history
Skin conditions – e.g. psoriasis / hereditary hemorrhagic telangiectasia

Skin cancer

Atopy – eczema / asthma / hay fever

Social history
Occupation:

 Are the skin problems worse at work?

 Do the skin problems improve when the patient is off from work?

 Is the patient exposed to any skin irritants or other hazardous substances?

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 – e.g. cellulitis from IV drug injection sites

Living situation:

 Own home/care home – adaptations / stairs?


 Who lives with the patient? – is the patient supported at home?
 Any carer input? – what level of care do they receive?
 Any recent changes at home that could be related to skin problems (e.g. new detergent causing allergic
reaction to clothing)

Activities of daily living:

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

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

39
Travel history
Where did the patient travel to?

How long was the patient there?

Is the patient aware of any exposure to infectious disease?

Sun exposure – was the skin problem worsened by sun exposure? (e.g. facial rash in lupus)

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. arthralgia in psoriatic arthritis).

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

Urinary – Volume of urine passed / Frequency / Dysuria / Urgency / Incontinence

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

Musculoskeletal – Bone and joint pain / Muscular pain

40
GYNAECOLOGICAL HISTORY TAKING
Posted by Dr Lewis Potter | History taking

Table of Contents
We’d really appreciate if you could leave us a rating
A gynaecological history involves asking questions relevant to the femalereproductive system. Some of
the questions are highly personal and therefore good communication skills and a respectful manner are
absolutely essential.

Taking a gynaecological history requires asking a lot of questions that are not part of the “standard” history
taking format and therefore it’s important to understand what information you are expected to gain.

Check out the gynaecological history taking mark scheme here.

Opening the consultation


Basics
 Introduce yourself (including your name and role)
 Confirm the patient’s details (name and date of birth)
 Explain the need to take a history
 Gain consent
 Ensure the patient is currently comfortable
41
Other relevant details
 It is useful to confirm the last menstrual period (LMP), gravidityand parity early on in the consultation,
as this will assist you in determining which questions are most relevant and what conditions are most
likely.
 LMP is useful to know when considering the possibility of ectopic pregnancy.
 Gravidity (G)is the number of times a woman has been pregnant, regardless of the outcome (e.g. G2).
 Parity (P) is the total number of pregnancies carried over the threshold of viability (typically 24 + 0
weeks).

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


Once the patient has had time to communicate their presenting complaint, you should then begin to explore
the issue with further open and closed questions.

Onset:
42
 When did the symptom start?

 Was the onset acute or gradual?

Duration:

 How long did the symptom last? (e.g. minutes, hours, days, weeks, months, years)

Severity:

 How severe does the patient feel the symptom is?

 Is it impacting significantly on their day to day life?

Course:

 Is the symptom worsening, improving, or continuing to fluctuate?

Cyclical:

 Do symptoms have any relationship to the menstrual cycle?

Intermittent or continuous:

 Is the symptom always present or does it come and go?

 If intermittent, how frequent is the symptom?

Precipitating factors:

 Are there any obvious triggers for the symptom?

Relieving factors:

 Does anything appear to improve the symptoms?

43
Associated features:

 Are there other symptoms that appear associated (e.g. fever/malaise)?

Previous episodes:

 Has the patient experienced this symptom previously?

 When did they last experience the symptom?

Abdominal or pelvic pain


The acronym SOCRATES provides a useful framework for asking about pain, as shown below.

Site:

 Where is the pain?

Onset:

 When did it start?

 Was the onset sudden or gradual?

Character:

 Is the pain sharp or a dull ache?

 Is the pain intermittent or continuous?

Radiation:

 Does the pain radiate anywhere? (e.g. shoulder tip pain can occur in ectopic pregnancy)

Associations:

 Are there any other symptoms associated with the pain?

Time course:

 What is the overall time course of the pain? (e.g. worsening, improving, fluctuating)

Exacerbating or relieving factors:

 Does anything make the pain worse or better?


44
 Dyspareunia refers to pain experienced during sexual intercourse

 Dysmenorrhea refers to pain associated with menstrual periods

Severity:

 On a scale of 0-10, how severe is the pain, if 0 is no pain and 10 is the worst pain you’ve ever experienced?

Gynaecological symptoms
Once you have completed exploring the history of presenting complaint, you need to move on to
more focused questioning relating to the common symptoms of gynaecological disease.

We have included a focused list of the key symptoms to ask about when taking a gynaecological history,
followed by some background information on each, should you want to know a little more.

Key symptoms to ask about


 Abdominal or pelvic pain (ectopic pregnancy, pelvic inflammatory disease, ovarain torsion)
 Post-coital vaginal bleeding (STIs, vaginitis, cervical ectropion, malignancy)
 Intermenstrual vaginal bleeding (STIs, malignancy, uterine fibroids, endometriosis)
 Post-menopausal bleeding (malignancy, vaginal atrophy, hormonal replacement therapy)
 Abnormal vaginal discharge (STIs, bacterial vaginosis)
 Dyspareunia (STIs, endometriosis, vaginal atrophy)
 Vulval skin changes and itching (vaginal atrophy, candida, STIs, lichen sclerosis)

Vaginal bleeding
Abnormal vaginal bleeding is an important symptom that can be relevant to a wide range of
gynaecological disease.

Post-coital bleeding

 Vaginal bleeding occurring after sexual intercourse

 Causes include cervical ectropion, infection (including STIs), vaginitis, malignancy (e.g. cervical cancer)

Intermenstrual bleeding

45
 Vaginal bleeding occurring between menstrual periods

 Causes include infection (including STIs), malignancy (e.g. cervical or endometrial cancer), uterine fibroids,
endometriosis, hormonal contraception (e.g. Mirena coil) and pregnancy

Post-menopausal bleeding

 Vaginal bleeding that occurs after the menopause (when there should be no further menstrual periods)

 Causes include malignancy (e.g. cervical or endometrial cancer), hormonal replacement therapy and vaginal
atrophy

Vaginal discharge
All healthy women will have some degree of regular vaginal discharge, so it is important to distinguish
between normal and abnormal vaginaldischarge when taking a gynaecological history.

You should ask if the patient has noticed any changes to the following characteristics of
their vaginal discharge:

 Volume

 Colour (e.g. green, yellow or blood-stained)

 Consistency (e.g. thickened or watery)

 Smell (e.g. fish-like smell in bacterial vaginosis)

Dyspareunia
Dyspareunia refers to pain that occurs during sexual intercourse. It has several causes including
infections, endometriosis, vaginal atrophy, malignancy and bladder inflammation.

The location of the pain varies between patients:

 Superficial dyspareunia – pain at the external surface of the genitalia

 Deep dyspareunia – pain deep in the pelvis

You should clarify:

46
 Duration of the symptom

 Location of the pain (e.g. superficial or deep)

 Nature of the pain (e.g. sharp, aching, burning)

Vulval skin changes and itching


Vulval skin changes and itching are common symptoms which can have several underlying causes
including:

 Infections such as candida (thrush), bacterial vaginosis and sexually transmitted infections

 Vaginal atrophy occurs in post-menopausal women and can lead to itching and bleeding of the vagina

 Lichen sclerosis appears as white patches on the vulva and is associated with itching

Other relevant symptoms


 Urinary symptoms such as frequency, urgency and dysuria can be relevant to gynaecological problems
(e.g. dyspareunia, vaginal prolapse, pelvic pain).
 Bowel symptoms such as a change in bowel habit or pain during defecation can be associated with
endometriosis.
 Fever is important to ask about when considering diagnoses such as pelvic inflammatory disease or other
infectious pathology.
 Malaise is a non-specific symptom, but its presence may indicate serious underlying pathology such as
anaemia and malignancy.
 Unintentional weight loss is a concerning feature that may indicate underlying malignancy.
 Abdominal distension is often a benign symptom, however, it can be associated with serious underlying
pathology such as ovarian cancer.

Ideas, Concerns and Expectations (ICE)


Ideas:

 Clarify what the patient’s thoughts are regarding their symptoms

 What do you think is going on?

Concerns:

47
 Explore any worries the patient may have regarding their symptoms

 Is there anything that you’re concerned about at the moment?

 Is there anything that is troubling you at the moment?

Expectations:

 Gain an understanding of what the patient is hoping to achieve from the consultation

 What were you hoping you’d get out of our consultation today?

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 so far.

It also provides an opportunity for the patient to correct any inaccurate information and expand further
on relevant aspects of the history.

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 so far: “Ok, so we’ve talked about your symptoms.”

 What you plan to cover next: “Now I’d like to discuss your past medical history.”

Menstrual history
A menstrual history involves clarifying the details of a woman’s menstrual cycle. It is an essential part of any
gynaecological history and it, therefore, it should not be missed.

Menstrual cycle details


Duration:

48
 Average duration is 5 days

 More than 7 days would be considered prolonged

 “How long do your periods typically last?”

Frequency:

 The average is 28 days

 “How often do your periods happen?”

 “Are they regular and predictable?”

Menstrual blood flow:

 This is an assessment of the volume of menstrual bleeding

 The average menstrual blood loss is approximately 40mls (8 teaspoons)

 Heavy menstrual blood loss is defined as more than 80mls (16 teaspoons) or having periods that last longer
than 7 days

 The definition of what is a “heavy period” compared to a “normal period” is highly subjective and therefore
you should ask the woman how the current periods compare to her usual loss. If the volume of bleeding is
impacting on the woman’s day to day life, it is significant.

 “Are your current periods heavier than your usual periods?”

 “Have you been flooding through sanitary towels?”

 “Have you been passing blood clots larger than a 10p coin?”

 “Are the heavy periods impacting your day to day life?”

Menstrual pain (dysmenorrhoea):

 It is common for women to experience abdominal and pelvic pain when menstruating.

 Menstrual pain can sometimes be severe and have a significant impact on a woman’s day to day quality of
life.

 Use the SOCRATES acronym shown above to further assess menstrual pain.

 “Have your recent periods been more painful than usual?”

49
Date of last menstrual period (LMP):

 Defined as the first day of the last menstrual period

 If late, consider performing a pregnancy test, particularly in the context of abdominal pain (to rule out
ectopic pregnancy).

Age at menarche:

 “At what age did you start having periods?”

 Early menarche is associated with an increased risk of breast cancer and cardiovascular disease

Menopause (if relevant):

 Age at menopause

 Ask about menopausal symptoms such as hot flushes and vaginal dryness

Contraception
Clarify the type of contraception currently used:

 Combined contraceptives – combined oral contraceptive pill, contraceptive patch)

 Progesterone only pill (POP)

 Depot injection (progesterone)

 Long-acting reversible contraceptives (LARCs) – hormonal coil, implant, copper coil

 Barrier methods

Ask about previous contraception history:

 It is useful to be aware of what the patient has previously tried, particularly if considering a change to their
current choice of contraception.
50
Reproductive plans
You should ask the patient if they are considering having children in the future (or are currently
trying to fall pregnant).

This is important to know when considering treatments for their gynaecological issue (e.g. you wouldn’t
suggest endometrial ablation or hysterectomy for menorrhagia if the patient was planning for a future
pregnancy).

Cervical screening
 Confirm the date of the last cervical screening test

 Confirm the result of the last cervical screening test

 Ask if the patient received any treatment if the cervical screening test was abnormal and check if follow up
is in place

 Ask if the patient received the HPV vaccine

Past gynaecological history


Previous gynaecological diagnoses and treatments:

 Ectopic pregnancy

 Sexually transmitted infections

 Endometriosis

51
 Bartholin’s cyst

 Cervical ectropion

 Malignancy (e.g. cervical, endometrial, ovarian)

Past medical history


It is important to ask about the patient’s non-gynaecological medical history, as these conditions may
impact the gynaecological problem and may themselves be impacted by or prevent the use of specific
gynaecological treatments.

Some examples are provided below:

 Migraine with aura – oestrogen containing medications (e.g. combined oral contraceptive) would be
contraindicated
 Previous venous thromboembolism (VTE) – oestrogen containing medications would be contraindicated
 Breast cancer (current or previous) – use of oestrogen containing medications would be usually be
contraindicated or require specialist input before being commenced
 Bleeding disorders (e.g. Von Willebrand’s) would be relevant if a patient presented with heavy vaginal
bleeding

Past surgical history


Previous surgical procedures such as :

 Abdominal or pelvic surgery

 Caesarian section

 Loop excision of the transitional zone (LETZ)

 Vaginal prolapse repair

 Hysterectomy

52
Obstetric history
It is important to take a brief obstetric history as part of a gynaecological assessment, as it may be
relevant. This is less detailed than a focused obstetric history.

You need to ask questions in a sensitive manner, as discussing previous miscarriages and terminations can
be very difficult for the patient.

Basic details
Gravidity: The number of times a woman has been pregnant, regardless of the outcome.

Parity:

 X (any live or stillbirth after 24 weeks)


 Y (number of pregnancies lost before 24 weeks)
Current pregnancy (if relevant)
 Gestation

 Symptoms of pregnancy (e.g. nausea, vomiting, back pain)

 Complications (e.g. pre-eclampsia, cervical neck incompetence)

 Recent scans results

Previous pregnancies
 Age of children

 Birth weight

 Mode of delivery

 Complications in the antenatal, perinatal, postnatal period

 If relevant, ask if the patient is currently breast feeding, as this is a contraindication to some types of
contraceptives (e.g. combined oral contraceptive)

53
Drug history
Hormonal replacement therapy (HRT)
 Duration of use

 Method of delivery (e.g. patch, gel, pessary)

 Frequency of treatment (e.g. cyclical or continuous)

 Type of treatment (e.g. combined or oestrogen only)

Other
 Recent antibiotics (increased the risk of vaginal thrush)
 Liver enzyme-inducing drugs (e.g. Rifampicin) can be a contraindication to commencing patients on the
combined oral contraceptive pill
 Other regular medication
 Over the counter medication (e.g. St John’s Wart can interfere with the metabolism of the COCP)
 Drug allergies

Family history
Important conditions to consider that may be relevant to a gynaecological presentation:

 Ovarian, endometrial and breast cancer – possible familial inheritance (e.g. BRCA gene)
 Bleeding disorders – menorrhagia can sometimes be the first presentation of an inherited bleeding
disorder (e.g. Von Willebrand disease)
 Venous thromboembolism (VTE) – patients who have a significant family history of VTE in a first-degree
relative (particularly if they were less than 45 when it developed) may be at increased risk of VTE and
therefore medications such as combined oral contraceptives, would often be contraindicated

Social history

54
Understanding the social context of a patient is absolutely key to building a complete picture of their health.
Social factors have a significant influence on a patient’s overall health and it’s therefore key that a
comprehensive social history is obtained.

Smoking:

 How many cigarettes a day?

 How long have they smoked for?

 If smoking more than 40 a day, the combined oral contraceptive would be contraindicated

 If a women over 35 years old is smoking more than 15 cigarettes a day, this would also be a
contraindication to the combined oral contraceptive

Alcohol and recreational drug use:

 How many units a week?

 Clarify the type, volume and strength of the alcohol

 Clarify the types of recreational drugs used

Weight:

 Obesity is associated with polycystic ovarian syndrome and carries a greater risk of endometrial cancer

 Anorexia can result in oligomenorrhoea (infrequent periods) or amenorrhoea (absence of menstruation)

 A raised BMI may be a contraindication to some treatments, including combined oral contraceptives

Home situation:

 Who lives with the patient?

 Do they feel like they are well supported?

 Is the patient independent or do they require assistance?

 How is the disease impacting on their ability to carry out activities of daily living?

 If receiving care input, what level are they requiring?

 All of these factors are important when planning management of the patient’s health problem.

Occupation:

 How is the disease process impacting their ability to work?

 Have they been exposed to any industrial carcinogens?


55
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. painful defecation secondary to
endometriosis).

Choosing which symptoms to ask about depends on the presenting complaint, however, a selection of
potentially relevant systemic symptoms to a gynaecological presentation are shown below.

Fever:

 Pelvic inflammatory disease

Weight loss:

 Malignancy

Respiratory:

 Dyspnoea (secondary to anaemia)

 Haemoptysis (secondary to endometriosis)

Gastrointestinal:

 Abdominal pain (secondary to menstruation)

 Painful defecation (secondary to endometriosis)

 Abdominal bloating (ovarian cancer)

Urinary:

 Frequency, dysuria and urgency (secondary to menopausal changes)

Musculoskeletal:

 Shoulder tip pain (ectopic pregnancy)

Dermatology:

56
 White patches on the vulva/vagina associated with pruritis (lichen sclerosis)

BACK PAIN HISTORY TAKING


57
Posted by Danielle Askey | History taking

Table of Contents
We’d really appreciate if you could leave us a rating
Back pain is a common presenting complaint associated with a wide range of acute and chronic medical
conditions. These can vary in severity from minor complaints such as muscular strain to life-threatening
conditions such as a dissecting aortic aneurysm. It is important that a thorough history is obtained to
identify any red flags indicating that a patient requires further diagnostic investigations. Check out the back
pain 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


58
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 back pain is like?”

History of presenting complaint


Gain further details about the back pain using the SOCRATESframework.

Site – where is the pain?

 Cervical / Thoracic / Lumbar / Sacral / Coccygeal / Paraspinal

 Pain directly overlying the spine – fracture/arthritis


 Paraspinal – muscle spasm/muscle sprain
 Lateral back pain – renal pain / pleuritic pain (e.g. pulmonary embolism or pneumonia) / hip pain
 Unilateral flank pain – pyelonephritis / renal colic
 Pain between the scapula – dissecting thoracic aortic aneurysm / myocardial infarction
To clarify the location of the pain it may be helpful to ask the patient to point to the location on themselves or
yourself.

Onset:

59
 When did the pain first start?

 Did the pain come on suddenly or has it been gradually worsening?

 What was the patient doing at the time of onset? – fracture and muscular related pain often has a sudden
onset associated with some form of trauma (fall/heavy lifting/sudden twisting motion)

Character:

 Is the pain constant (e.g. spinal fracture/inflammatory arthritis) or intermittent (e.g. muscular spasm)?
 Is the pain present at rest? / Does the pain wake the patient at night? – consider inflammatory causes (e.g.
rheumatoid arthritis/ankylosing spondylitis) and malignancy (e.g. metastatic deposits)
 Has the patient suffered pain like this before? / What was felt to be the cause? / How was it managed?

 Type of pain – sharp / dull ache / burning / tearing / crushing

 Pain described as “burning” in nature is typically neuropathic in origin (e.g. nerve root compression)

 Tearing/ripping thoracic back pain is typically associated with aortic dissection

 Crushing thoracic back pain is associated with myocardial infarction

 Sharp pain is less specific but is associated with acute spinal fracture, muscular spasm and pulmonary
embolism (pleuritic)

Radiation (“Does the pain move anywhere else?”):

 Buttocks or legs – sciatic nerve compression/irritation (“sciatica”)


 Upper/lower limbs – radiculopathy (spinal nerve root compression)

 Flank to the ipsilateral groin – renal colic

 Chest – myocardial infarction / dissecting aortic aneurysm

 Epigastrium – peptic ulcer disease


 Abdomen – abdominal aortic aneurysm dissection / ischaemic bowel

Associated symptoms:

 Sensory disturbances – radiculopathy / cauda equina syndrome (e.g. saddle paresthesia) / spinal cord
compression

60
 Motor disturbances (weakness) – cord compression (displaced fracture/prolapsed
intervertebral disc/epidural abscess/haematoma)
 Urinary retention – cauda equina syndrome / spinal cord compression / severe back pain
 Urinary incontinence – cauda equina syndrome / spinal cord compression
 Other urinary symptoms (e.g. dysuria, increased frequency, haematuria) – urinary tract infections /
pyelonephritis
 Fever/chills – pyelonephritis / pneumonia / vertebral discitis
 Nausea and vomiting – pyelonephritis / renal colic / myocardial infarction
 Fatigue/malaise – pyelonephritis / inflammatory arthritis / malignancy
 Weight loss – malignancy
 Haematemesis or melaena – peptic ulcer / duodenal ulcer / gastrointestinal malignancy
 Early morning stiffness – ankylosing spondylitis / rheumatoid arthritis
 Diaphoresis/dyspnoea – myocardial infarction
 Muscular spasms – can occur alongside fracture/trauma

Time course:

 Duration –minutes / hours / days / weeks


 Course – worsening / improving / fluctuating

Exacerbating/relieving factors:

 Does anything make the pain worse?

 Sneezing or coughing – acute fracture / pulmonary embolism / pneumonia


 Worse following meals – duodenal ulcer
 Worse at night – ankylosing spondylitis / spinal malignancy / radiculopathy
 Physical activity – osteoarthritis / fracture

 Does anything relieve or reduce the pain?

 Physical activity – ankylosing spondylitis / rheumatoid arthritis


 Analgesic medication

Severity – on a scale of 0-10 how severe is the pain?

61
Red flags for back pain (history only) ¹
Cauda equina syndrome:

 Severe or progressive bilateral neurological deficit of the legs, such as major motor weakness with knee
extension, ankle eversion, or foot dorsiflexion

 Recent-onset urinary retention and/or urinary incontinence

 Recent-onset faecal incontinence

 Perianal or perineal sensory loss (saddle anaesthesia or paraesthesia)

Spinal fracture:

 Sudden onset of severe central spinal pain which is relieved by lying down

 There may be a history of major trauma (such as a road traffic collision or fall from a height), minor trauma,
or even just strenuous lifting in people with osteoporosis or those who use corticosteroids

Cancer:

 Aged 50 or older

 Gradual onset of symptoms

 Severe unremitting pain that remains when the person is supine, aching night pain that prevents or disturbs
sleep, pain aggravated by straining (e.g. opening bowels, coughing or sneezing), and thoracic pain

 Localised spinal tenderness

 No symptomatic improvement after four to six weeks of conservative lower back pain therapy

 Unexplained weight loss

 Past history of cancer — breast, lung, gastrointestinal, prostate, renal, and thyroid cancers are more likely to
metastasise to the spine

Infection (such as discitis, vertebral osteomyelitis, or spinal epidural abscess):

 Fever

 Tuberculosis, or recent urinary tract infection

62
 Diabetes

 History of intravenous drug use

 HIV infection, use of immunosuppressants, or the person is otherwise immunocompromised

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”
 What you plan to cover next –“Now I’d like to discuss your past medical history and your medications”

Past medical history


Previous episodes of back pain:

 When?

 Were the episodes similar to the current?

 Did the patient seek medical attention?

63
 Was a diagnosis made?

Previous treatment for back pain (e.g. physiotherapy, analgesia, steroid injections)

Surgical history – “Have you ever had any spinal surgery?”

Osteoporosis – increased risk of spinal fracture

Trauma – “Have you ever injured your back in the past?”

Acute hospital admissions – When and why?

Congenital spinal problems (e.g. scoliosis)

Malignancy – consider metastases to the spine

Cardiovascular disease – myocardial infarction / aortic aneurysms

Recent infections – osteomyelitis / vertebral discitis

Immunosuppression – osteomyelitis / vertebral discitis

Depression – associated with chronic and recurring back pain ²

Drug history
Regular medications

Analgesia for back pain:

 Paracetamol, NSAIDs, opioid analgesics (i.e. codeine, tramadol or oral morphine)

 Benzodiazepines to relieve muscle spasms

 Gabapentin/Pregabalin are often used for chronic back pain

Corticosteroids – increased risk of vertebral fractures if using long-term

Over the counter drugs – important to clarify what analgesics they are purchasing over the counter to
ensure they are not overdosing (e.g. using regular paracetamol in addition to co-codamol)

64
Herbal remedies

ALLERGIES – ensure to document these clearly

Family history
Rheumatological disease – rheumatoid arthritis/ankylosing spondylitis

Degenerative disc disease – musculoskeletal lower back pain

Osteoporosis – fractures

Cardiovascular disease – myocardial infraction/aortic aneurysm

Malignancy – clarify the type of cancer and age of diagnosis

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 – history of alcohol abuse is
associated with pancreatitis

Recreational drug use – e.g. intravenous drug use – osteomyelitis / vertebral discitis / epidural abscess

Occupation:

 What does the job involve? (e.g. heavy lifting, repetitive movements, sitting for prolonged periods, driving)
 Is the patient currently able to do their job?

 Is the patient satisfied in their job? (job dissatisfaction is associated with chronic lower back pain,
furthermore, the longer someone is absent from work due to back pain, the less likely they are to return to
work³)
Stress – emotional stress can be associated with musculoskeletal lower back pain

Diet – obesity is a strong risk factor for musculoskeletal back pain

Exercise – baseline level of the patient’s day to day activity (patients participating in contact sports or
weightlifting/strength sports may be at an increased risk of back injuries)
65
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?
 What is their normal level of mobility? – Do they use mobility aids such as walking sticks? Is the back pain
impacting their mobility?

Activities of daily living:

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

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

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. weight loss secondary to malignancy). 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

Urinary – Volume of urine passed / Frequency / Dysuria / Urgency / Incontinence

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

Musculoskeletal – Bone and joint pain / Muscular pain

Dermatology – Rashes / Skin breaks / Ulcers / Lesions

66
HEADACHE HISTORY TAKING
Posted by Jennifer Rodgers | History taking

Table of Contents
We’d really appreciate if you could leave us a rating
Headache is a common presenting complaint and certainly something you’ll encounter many times over your
career. The vast majority of headaches are not life-threatening, with tension headache and migraine being the
most common diagnoses. Headache is however also associated with a number of serious conditions and
therefore it is essential you are able to take a comprehensive headache history and identify red flags that
indicate the need for further investigation. Check out the headache history taking OSCE mark scheme here.

HPC
PAST MEDICAL HX
DRUG HX
FAMILY HX
SOCIAL HX
SYSTEMIC ENQUIRY
INTERACTIVE MARK SCHEME
MARK SCHEME (PDF)

67
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 headache”

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


The aim now is to encourage the patient to give further details about their complaint to allow you to narrow
the differential diagnosis. One useful way to gain further details about a headache is to use
the SOCRATES system of questions as shown below.

Site – unilateral (e.g. migraine) / frontal bilateral (e.g. tension headache)

Onset:

 Was the onset acute or gradual? (sudden onset “thunderclap” headache is suggestive
of subarachnoid haemorrhage)
68
Character – aching / throbbing / pounding / pulsating / pressure / pins and needles / stabbing

Radiation – neck (meningitis) / face (e.g. trigeminal neuralgia) / eye (e.g. acute closed angle glaucoma)

Associated symptoms:

 Nausea/vomiting – may suggest raised intracranial pressure (ICP)


 Visual disturbance – aura related / intracranial lesion / bleeding / stroke
 Photophobia – raised ICP / meningitis
 Neck stiffness – meningitis (may be related to infection or subarachnoid haemorrhage)
 Fever – suggestive of an infective process (e.g. bacterial meningitis/abscess)
 Rash – non-blanching purpuric rash may indicate meningococcal sepsis
 Weight loss – suggestive of malignancy – consider cerebral metastases
 Sleep disturbance – headaches causing sleep disturbance are concerning (raised ICP)
 Temporal region tenderness – consider temporal arteritis
 Neurological deficits – weakness / sensory disturbance / impaired coordination / cognitive symptoms /
altered level of consciousness – consider space-occupying lesions / intracranial bleeding / stroke

Timing:

 Duration of headache?

 Is it episodic?

 Any clear pattern?

 Diurnal variation?

 Chronic headaches – in a month of 30 days, for how many of those days would the patient have a headache?

Exacerbating/relieving factors:

 Exacerbating factors – are there any obvious triggers for the symptom? (e.g. caffeine / codeine / stress /
postural change)
 Relieving factors – does anything appear to improve the symptoms(e.g. improvement upon lying flat
suggestive of reduced ICP).
69
Severity:

 Ask the patient to rate the pain on a scale of 1-10

 Is the pain getting worse?

 How is it impacting their daily life?

Red flags
Red flags within a headache history are many and varied, so familiarise yourself with common
patterns.

 A headache of sudden onset, reaching maximum intensity by five minutes (suggestive of subarachnoid
haemorrhage)
 Fever with a worsening headache, meningeal irritation and change in mental status (viral/bacterial
meningitis)
 New-onset focal neurological deficit, personality change or cognitive dysfunction (intracranial
haemorrhage/ischaemic stroke/space occupying lesion)
 Decreased level of consciousness

 Head trauma (more significant if within the last three months)


 Headache which is posture dependent (e.g. worse on lying down and coughing with raised ICP).
 Headache associated with tenderness in the temporal region (unilateral or bilateral) and jaw claudication
(temporal arteritis)

 Headache associated with severe eye pain/blurred vision/nausea/vomiting/red eye (acute angle closure
glaucoma)
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.

70
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


Previous episodes of headache/migraine?

Previous intracranial bleeds? (e.g. subarachnoid haemorrhage)

Head trauma in last three months?

History of malignancy?

Other medical conditions?

Previous surgery? – e.g. CSF shunting (blocked/infected shunts present with headache)

Drug history
Regular prescribed medication?

Anticoagulants or antiplatelets? – e.g. Warfarin / Aspirin

Analgesia for headache?

 Clarify dosages and frequencies

71
 In a month with 30 days, on how many days would they use painkillers?

 Do the painkillers fully relieve the pain?

Over the counter drugs or herbal remedies?

ALLERGIES – document these clearly

Family history
Neurological diagnoses in first degree relatives? – e.g. migraine

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

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

Recreational drug use – headache may be withdrawal related

Living situation:

 House / Flat – stairs/adaptations


 Who lives with the patient? – important when considering discharging home from the hospital
 Any carer input? – what level of care do they receive?

Activities of daily living:

 Is the patient independent / able to fully care for themselves?

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

72
 Is the headache interfering significantly with their daily life?

Occupation – clarify their role and daily responsibilities

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. neck stiffness in meningitis).

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

Urinary – Volume of urine passed / Frequency / Dysuria / Urgency / Incontinence

Musculoskeletal – Bone and joint pain / Muscular pain

Dermatology – Rashes / Skin breaks / Ulcers / Lesions

73
RHEUMATOLOGICAL HISTORY TAKING – OSCE GUIDE
Posted by Merina Kurian | History taking

Table of Contents
We’d really appreciate if you could leave us a rating
Taking a rheumatological history is an important skill that can be assessed in the OSCE setting. It usually
involves taking a history of a joint problem, with the patient also mentioning other systemic features of
rheumatological disease. 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 history of rheumatological
pathology. Check out the rheumatological history taking mark scheme here.

HPC
PAST MEDICAL HX
DRUG HX
FAMILY HX
SOCIAL HX
SYSTEMIC ENQUIRY
CLOSING THE CONSULTATION
INTERACTIVE MARK SCHEME
MARK SCHEME (PDF)

74
Introduction
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 your joint pain”

History of presenting complaint


Key rheumatological complaints
PRISMS

 Pain
 Rashes and skin lesions
 Immune
 Stiffness
 Malignancy
 Swelling and Sweats

Pain
If pain is a symptom, clarify the details of the pain using SOCRATES
75
 Site – where is the pain? (e.g. monoarthritis vs polyarthritis)
 Onset – when did it start? / sudden vs gradual? / associated with trauma?
 Character – how would you describe the pain? (e.g. sharp/dull ache/burning)
 Radiation – does the pain move anywhere else?
 Associations – other symptoms associated with the pain? (e.g. stiffness)
 Time course – worsening/improving/fluctuating/time of day dependent? (e.g. rheumatoid arthritis worse
in mornings vs osteoarthritis worst during/after activity)
 Exacerbating / Relieving factors – does anything make the pain worse or better?
 Severity – on a scale of 0-10, how severe is the pain?

Rashes and skin lesions


 See the dermatological history guide
 Also, ask about nail changes (psoriasis)

Immune
Systemic sclerosis: CREST

 Calcinosis – “Have you noticed any skin changes?”


 Raynaud’s – “Do you notice that your fingertips change colour, particularly in the cold or during stress?”
 Esophageal dysmotility – “Do you ever find it difficult to swallow?”
 Sclerodactyly – “Have you noticed any thickening/tightening of the skin of your fingers?”
 Telangiectasia – “Do you notice small spider-like red lines on your face or elsewhere?”

Systemic Lupus Erythematosus (SLE)

 Constitutional symptoms (fatigue, fever, weight changes)

 Musculoskeletal symptoms (arthralgia, myalgia) – “Do you have any aching in any of your joints or muscles
currently?”
 Dermatological symptoms (malar rash/butterfly rash), photosensitivity, discoid lupus) – “Have you noticed
any rashes or skin changes recently?”
 Renal (acute nephritic disease) – “Have you noticed any blood or other changes in your urine?”
 Neuropsychiatric (seizure, psychosis) – “Have you noticed any changes in your thoughts or mood?”
 Pulmonary (pneumonitis, interstitial lung disease) – “Have you felt more short of breath recently?”
 Gastrointestinal (nausea, dyspepsia, abdominal pain)

 Cardiac (pericarditis, myocarditis) – “Have you experienced any chest pain recently?”

76
 Haematological (leukopenia, anaemia, thrombocytopenia) – “Have you felt more fatigued or found that you
are bruising more easily recently?”

Sjogren’s syndrome

 Dry eyes

 Dry mouth

 Chronic cough

Stiffness
 Reduced range of movement

 Locking of the joint

 Functional difficulties (e.g. writing, buttoning up shirt, brushing hair)

Malignancy
Ask about B symptoms to rule out malignancy:

 Fever

 Night sweats

 Weight loss

Swelling and Sweats


 Joint swelling – confirm which joints are affected and timescale for onset
 If joint swelling is present, is there associated erythema? – gout/septic arthritis

Ask about extra-articular manifestations of rheumatological joint disease:


 Red/painful eyes – uveitis – ankylosing spondylitis
 Dry eyes – Sjogren’s syndrome
 Breathing difficulties – interstitial lung disease – RA/SLE
 Urethritis – reactive arthritis
 Fever – inflammatory arthropathies/septic arthritis

Ask about history of recent infections

77
 Septic arthritis (often the causative organism is from another source e.g. urine)

 Reiter’s syndrome (STIs)

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”
 What you plan to cover next – “Now I’d like to discuss your past medical history and your medications”

Past medical history


Rheumatological disease

Autoimmune conditions

Peptic ulcers/duodenal ulcers/ischaemic heart disease/ischaemic stroke (NSAIDS would be


contraindicated)

ALLERGIES
78
Past surgical history
Joint surgery/replacements

Drug history
Analgesics

Immunosuppressants:

 Corticosteroids – e.g. prednisolone

 anti-TNF – e.g. infliximab

 Biologics – e.g. rituximab

Family history
Ask about any history of rheumatological disease in first-degree relatives.

Social history
Occupation:

 Are they currently working?

 Are their joint problems impacting their ability to work?

Mobility – How does the patient mobilise? – e.g. wheelchair/stick/zimmer frame/independent

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

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

79
Recreational drug use – IV drug use is a potential source of joint sepsis

Living situation:

 Own home/care home – adaptations/stairs?


 Who lives with the patient? – is the patient supported at home?
 Any children?

 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?

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. arthralgia in psoriatic arthritis).

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

Urinary – Volume of urine passed / Frequency / Dysuria / Urgency / Incontinence

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

Musculoskeletal – Bone and joint pain / Muscular pain

80
OBSTETRIC HISTORY TAKING
Posted by Dr Lewis Potter | History taking

Table of Contents
We’d really appreciate if you could leave us a rating
An obstetric history involves asking questions relevant to a patient’s current and previous pregnancies.
Some of the questions are highly personal and therefore good communication skills and a respectful
manner are absolutely essential.

Taking an obstetric history requires asking a lot of questions that are not part of the “standard” history
taking format and therefore it’s important to understand what information you are expected to gain.

It’s also worth noting that before 18 weeks gestation, most obstetric conditions are unlikely and therefore
your history should focus more on the gynaecological aspect (e.g. abdominal pain at 8 weeks gestation could
be an ectopic pregnancy).

Check out the obstetric history taking mark scheme here.

Opening the consultation


Basics
81
 Introduce yourself (including your name and role)
 Confirm the patient’s details (name and date of birth)
 Explain the need to take a history
 Gain consent
 Ensure the patient is currently comfortable

Key pregnancy details


 It is useful to confirm the gestational age, gravidity and parityearly on in the consultation, as this will
assist you in determining which questions are most relevant and what conditions are most likely.
 Gestational age, gravidity and parity would also usually be included at the beginning of any documentation
or presentation of the patient.

 Gravidity (G) is the number of times a woman has been pregnant, regardless of the outcome (e.g. G2).
 Parity (P) is the total number of pregnancies carried over the threshold of viability (typically 24 + 0 weeks).

Example of Gravidity and Parity calculation


A patient is currently 26 weeks pregnant and already has two other children of her own. She also reports
having had a miscarriage at 10 weeks and a stillbirth at 28 weeks.

 G5: The patient’s gravidity is 5 because she has had 5 pregnancies in total, regardless of the outcome.
 P4: The patient’s parity would be 4 because she has had 4 pregnancies which were carried beyond 24+0
weeks gestation and a miscarriage lost at 10 weeks gestation.
How does Parity work for twins?
 A British Journal of Gynaecology study suggests that a mother who has carried twins to a viable gestational
age should be defined as P1.
 However, in clinical practice, only 20% of UK Obstetricians and Midwives follow this definition, with the
remaining 80% referring to twin pregnancy as P2.
 As a result, you should be aware that in clinical practice, a mother who has carried twins to a viable
gestational age will often be referred to as P2, but from an academic perspective, they would be deemed as
P1.

Presenting complaint
It’s important to use open questioning to elicit the patient’s presenting complaint:
82
 “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


Once the patient has had time to communicate their presenting complaint, you should then begin to explore
the issue with further open and closed questions.

Onset:

 When did the symptom start?

 Was the onset acute or gradual?

Duration:

 How long did the symptom last? (e.g. minutes, hours, days, weeks, months, years)

Severity:

 How severe does the patient feel the symptom is?

 Is it impacting significantly on their day to day life?

Course:

 Is the symptom worsening, improving, or continuing to fluctuate?

83
Intermittent or continuous:

 Is the symptom always present or does it come and go?

 If intermittent, how frequent is the symptom?

Precipitating factors:

 Are there any obvious triggers for the symptom?

Relieving factors:

 Does anything appear to improve the symptoms?

Associated features:

 Are there other symptoms that appear associated (e.g. fever/malaise)?

Previous episodes:

 Has the patient experienced this symptom previously?

 When did they last experience the symptom?

Pain
The acronym SOCRATES provides a useful framework for asking about pain (e.g. abdominal pain), as shown
below.

Site:

 Where is the pain?

Onset:

 When did it start?

 Was the onset sudden or gradual?

84
Character:

 Is the pain sharp or a dull ache?

 Is the pain intermittent or continuous?

Radiation:

 Does the pain radiate anywhere?

Associations:

 Are there any other symptoms associated with the pain?

Time course:

 What is the overall time course of the pain? (e.g. worsening, improving, fluctuating)

Exacerbating or relieving factors:

 Does anything make the pain worse or better?

Severity:

 On a scale of 0-10, how severe is the pain, if 0 is no pain and 10 is the worst pain you’ve ever experienced?

Obstetric symptoms
Once you have completed exploring the history of presenting complaint, you need to move on to
more focused questioning relating to the symptoms that may be relevant to pregnancy. We have
included a focused list of the key symptoms to ask about when taking an obstetric history, followed by some
background information on each, should you want to know a little more.

Key symptoms to ask about


 Nausea and vomiting (hyperemesis gravidarum)
 Reduced fetal movements (may be a sign of fetal distress)
 Vaginal bleeding (antepartum haemorrhage, placenta praevia, cervical causes)
 Abdominal pain (urinary tract infection, placental abruption, constipation, pelvic girdle pain)
 Vaginal loss (abnormal vaginal discharge or spontaneous rupture of membranes)
 Headache/Visual disturbance/Epigastric pain (pre-eclampsia)
 Pruritis (obstetric cholestasis)
85
Nausea and vomiting
Nausea and vomiting are very common in pregnancy but are usually mild and only require reassurance
and advice.

Nausea and vomiting in pregnancy usually begin between the fourth and seventh weeks of gestation,
peaks between the ninth and sixteenth weeks and resolves by around the 20th week of pregnancy.

Persistent vomiting and severe nausea can progress to hyperemesis gravidarum. Hyperemesis
gravidarum refers to persistent and severe vomiting leading to dehydration and electrolyte disturbance,
weight loss and ketonuria. ¹

Reduced fetal movements


Women should start to feel fetal movements between 16 to 24 weeks gestation. Primigravida women
will often not feel fetal movements until after 20 weeks gestation. A mother will know what is the “usual”
amount of fetal movements she experiences and therefore if a reduction in fetal movements is reported, it
should be taken very seriously.

Reduced fetal movements are associated with adverse pregnancy outcomes, including stillbirth, fetal
growth restriction, placental insufficiency, and congenital malformations. ²

You should therefore always ask about fetal movements one the patient is of the appropriate gestation to be
able to feel them:

 “Have you noticed any change in the amount of baby’s movement?”

Vaginal bleeding
Abnormal vaginal bleeding is an important symptom that can be relevant to a wide range of obstetric and
gynaecological diseases.

It is important to ask about pain, associated trauma (including domestic violence), fever/malaise,
recent ultrasound scan results (e.g. position of the
placenta), cervical screening history, sexual history and pastmedical history to help narrow the
differential diagnosis.

You should also ask about fatigue if anaemia is suspected and symptoms of hypovolaemic shock (e.g. pre-
syncope/syncope) if large blood loss is suspected.

Vaginal discharge
All healthy women will have some degree of regular vaginal discharge, so it is important to distinguish
between normal and abnormal vaginaldischarge when taking an obstetric history.

86
You should ask if the patient has noticed any changes to the following characteristics of
their vaginal discharge:

 Volume

 Colour (e.g. green, yellow or blood-stained would suggest infection)

 Consistency (e.g. thickened or watery)

 Smell (e.g. fish-like smell in bacterial vaginosis)

Urinary symptoms
Urinary tract infections are common in pregnancy and need to be treated promptly. Untreated urinary tract
infections in pregnancy have been associated with increased risk of fetal death, developmental delay and
cerebral palsy.

Common symptoms of urinary tract infections include:

 Dysuria – pain when passing urine

 Frequency – increased frequency of passing urine

 Urgency – a sudden need to pass urine, with no earlier warning

 Fever

Headache/visual changes/swelling
Pre-eclampsia is a relatively common condition in pregnancy which is characterised by maternal
hypertension, proteinuria, oedema, fetal intrauterine growth restriction and premature birth. The condition
can be life-threatening for the mother and the fetus. As a result, it is essential to ask about symptoms of pre-
eclampsia as part of every patient review during pregnancy.

The key symptoms to ask about include:

 Headache (typically severe and frontal)

 Swelling of the hands, feet and face (oedema)

 Pain in the upper part of the abdomen (epigastric tenderness)

 Visual disturbance (blurring of vision or flashing lights)

 Reduced fetal movements

87
Other relevant symptoms
 Fever is important to ask about when considering infectious pathology (e.g. urinary tract infections,
cervical infections, chorioamnionitis).
 Fatigue is a non-specific symptom, but its presence may indicate anaemia or other systemic pathology.
 Weight loss is a symptom of hyperemesis gravidarum and other significant conditions (e.g. malignancy,
anorexia nervosa).
 Pruritis can occur in obstetric cholestasis.

Ideas, Concerns and Expectations (ICE)


Ideas:

 Clarify what the patient’s thoughts are regarding their symptoms

 What do you think is going on?

Concerns:

 Explore any worries the patient may have regarding their symptoms

 Is there anything that you’re concerned about at the moment?

 Is there anything that is troubling you at the moment?

Expectations:

 Gain an understanding of what the patient is hoping to achieve from the consultation

 What were you hoping you’d get out of our consultation today?

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 so far.

It also provides an opportunity for the patient to correct any inaccurate information and expand further
on relevant aspects of the history.

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.

88
Signposting
Signposting involves explaining to the patient:

 What you have covered so far: “Ok, so we’ve talked about your symptoms.”

 What you plan to cover next: “Now I’d like to discuss your past medical history.”

Current pregnancy
Gestation
Clarify the current gestational age of the pregnancy (e.g. 26 weeks and 5 days would be written as
“26+5”).

Accurate estimation of gestation and estimated date of delivery (EDD) is performed using
an ultrasound scan to measure the crown-rump length.

Scan results
Women are offered an ultrasound scan to check for fetal anomalies between 18+0 and 20+6 weeks. You
should ask about the results of the scan (or check the medical records if the patient is unsure). The key
findings you should ask about include:

 Growth of the fetus – clarify if it was within normal limits for the current gestation

 Placental position – if embedded in the lower third of the uterine cavity there is an increased risk of
placenta praevia

 Fetal anomalies – note any abnormalities identified

Screening
There are several types of screening that women are offered during pregnancy. You should clarify if the
patient has opted for screening and if so, what the results were.

 Down’s syndrome screening


 Rhesus status and the presence of any antibodies
 Hepatitis B, HIV and syphilis.

Other details of the pregnancy


 Singleton or multiple gestation
89
 Clarify if the patient took folic acid prior to conception and during the first trimester
 Planned mode of delivery (e.g. vaginal or Caesarian section)
 Medical illness during pregnancy (clarify what type of illness and if they are receiving any treatment)

Immunisation history
Check the patient is currently up to date with their vaccinations:

 Flu vaccination

 Whooping cough vaccination

 Hepatitis B vaccination (if at risk)

Mental health history


Pregnancy can have a significant impact on maternal mental health and therefore it is essential that patients
are screened for symptoms suggestive of psychiatric illness (e.g. depression, bipolar disorder,
schizophrenia).

Ask about previous mental health diagnoses and any current thoughts of self-harm and/or suicide if
relevant.

Previous obstetric history


It is important to ask about a woman’s previous obstetric history, as this can often help inform the
assessment of risk in the current pregnancy and have implications for the mode of delivery.

Gravidity and Parity


Gravidity is the number of times a woman has been pregnant, regardless of the outcome.

Parity is the total number of pregnancies carried over the threshold of viability (typically 24 + 0 weeks).

Term pregnancies (>24 weeks)


Gestation at delivery:

 Previous pre-term labour increases the risk of pre-term labour in later pregnancies

90
Birth weight:

 A high birth weight in previous pregnancies raises the possibility of previous gestational diabetes

 A low birth weight (small for gestational age) in a previous pregnancy increases the risk of a further small
for gestational age baby

Mode of delivery:

 Spontaneous vaginal delivery

 Assisted vaginal delivery (e.g. forceps)

 Caesarian section (will have implications for choice of future mode of delivery)

Complications:

 Antenatal period – pre-eclampsia, gestational diabetes, gestational hypertension, placenta praevia, shoulder
dystocia

 Postnatal period – post-partum haemorrhage, perineal/rectal tears during delivery, retained products of
conception

Assisted reproduction:

 Clarify if IVF or other assisted reproductive techniques were used for any previous pregnancies

Stillbirth
As stated below, asking about stillbirths need to be done in a sensitive manner.

A stillbirth is when a baby is born dead after 24 completed weeks of pregnancy.

 Clarify the gestation of the stillbirth

Other pregnancies (<24 weeks)


Questions about miscarriage, terminations and ectopic pregnancies need to be asked in a sensitive manner
in a private setting. It can be very difficult for women to discuss these topics. These questions should only
be asked when relevant and by a person who is competent to do so.

91
Miscarriage
A miscarriage is the loss of a pregnancy before 24 weeks gestation.

Gestation:

 Clarify the trimester at which the miscarriage occurred.

 Miscarriage is most common in the first trimester.

Other details:

 Was medical or surgical management required for the miscarriage?

 Was there any cause identified for the miscarriage? (e.g. genetic syndromes)

Termination of pregnancy
A termination of pregnancy (abortion) is the medical process of ending a pregnancy so it doesn’t result
in the birth of a baby. The pregnancy is ended either by taking medications or having a minor surgical
procedure.

 Clarify the gestation and method of management (e.g. medical or surgical)

Ectopic pregnancy
An ectopic pregnancy is when a fertilised egg implants itself outside of the uterus, usually in one of the
fallopian tubes.

 Clarify the site of the ectopic pregnancy

 Ask about the management of the ectopic pregnancy (e.g. expectant, medical, surgical)

Gynaecological history
Cervical screening (known previously as cervical smears):

 Confirm the date of the last cervical screening test

 Confirm the result of the last cervical screening test


92
 Ask if the patient received any treatment if the cervical screening test was abnormal and check if follow up
is in place

Previous gynaecological diagnoses and treatments:

 Sexually transmitted infections

 Endometriosis

 Bartholin’s cyst

 Cervical ectropion

 Malignancy (e.g. cervical, endometrial, ovarian)

Past medical history


A patient’s medical history is highly relevant, as some medical conditions can worsen during pregnancy
and/or have implications for the developing fetus.

Examples of medical conditions that are important to be aware of during pregnancy are shown below.

Diabetes (type 1 or 2):

 Blood glucose control can deteriorate significantly during pregnancy resulting in poor maternal health and
fetal complications (e.g. macrosomia)

Hypothyroidism:

 Untreated or undertreated hypothyroidism can result in congenital hypothyroidism with significant


neurodevelopmental impact.

Epilepsy:

 Seizures during pregnancy pose a risk to both the mother and fetus (e.g. miscarriage)

 Many anti-epileptic drugs are teratogenic

Previous venous thromboembolism (VTE):

93
 Pregnancy is a pro-thrombotic state and therefore women who have previously had a venous
thromboembolism are high risk for further VTEs.

 They may require prophylactic low molecular weight heparin to reduce their risk.

Blood-borne viruses:

 HIV, Hepatitis B, Hepatitis C

 These pose a risk to the fetus during childbirth (vertical transmission)

Genetic disease:

 Cystic fibrosis, Sickle-cell disease, Thalassaemias

Surgical history
Previous surgical procedures such as:

 Abdominal or pelvic surgery – can result in adhesions that complicate Caesarian sections

 Caesarian section – increased risk of uterine rupture in subsequent pregnancies

 Loop excision of the transitional zone (LETZ) – increased risk of cervical incompetence

Drug history
It is essential to gain an accurate overview of the medications the patient is currently and has previously
taken during the pregnancy. The first trimester is when the fetus is most at risk of teratogenicity from
drugs, as this is when organogenesis occurs.

Regular medications
Clarify the medications the patient has been taking since falling pregnant, noting which they are still taking
and which they have now stopped.

Some examples of drugs that are known to be teratogenic include:

94
 ACE inhibitors

 Sodium valproate

 Methotrexate

 Retinoids

 Trimethoprim

Contraception
Ask if the patient was using contraception prior to falling pregnant and if so, clarify what method of
contraception was being used. Check the patient has stopped their contraception or had their
contraceptive device removed (e.g. coil, implant).

Medications frequently used during pregnancy


Some medications are commonly used in pregnancy to both reduce the risk of fetal malformations and treat
the symptoms of pregnancy.

Some examples of medications commonly used in pregnancy include:

 Folic acid (400μg) – recommended daily for the first trimester of pregnancy to reduce the risk of neural
tube defects in the developing fetus

 Oral iron – frequently used in pregnancy to treat anaemia

 Antiemetics – frequently used in pregnancy to manage nausea and vomiting (e.g. hyperemesis gravidarum)

 Antacids – frequently used to manage gastro-oesophageal reflux symptoms during pregnancy

 Aspirin

Over the counter medications


You should clarify if the patient is using any over the counter medications, as some of these have the
potential to impact the pregnancy:

 Analgesics – Paracetamol, Ibuprofen, Codeine

 Herbal remedies

Allergies
95
It’s essential to clarify any allergies the patient may have and document these clearly in the notes, including
the type of allergic reaction the patient experienced.

Family history
Taking a brief family history can help to further assess the risk of adverse outcomes to the mother and fetus
during pregnancy. This can also help inform discussions with parents about the risk of their child having a
specific genetic disease (e.g. cystic fibrosis).

Some important areas to cover include:

 Inherited genetic conditions (e.g. cystic fibrosis, sickle-cell disease)


 Type 2 diabetes (first-degree relative) – increased risk of developing gestational diabetes
 Pre-eclampsia (maternal mother or sister) – increased risk of developing pre-eclampsia

Social history
Understanding the social context of a patient is absolutely key to building a complete picture of their health.
Social factors have a significant influence on a patient’s pregnancy and it’s therefore key that a
comprehensive social history is obtained.

Smoking
 How many cigarettes a day?

 How long have they smoked for?

 Would they be interested in support from a stop smoking service?

 Smoking increases the risk of a small for gestational age baby

Alcohol
 How many units a week?

 Clarify the type, volume and strength of the alcohol


96
 Would they be interested in support from an alcohol cessation service?

Recreational drugs
It is important to ask about recreational drug use, as these can potentially have significant consequences on
the mother and developing fetus (e.g. cocaine use increases the risk of placental abruption).

If recreational drug use is identified, patient’s can be offered input from drug cessation services.

Diet and weight


 Clarify if the patient is managing to eat a balanced diet whilst pregnant

 Ask about the patient’s current weight – obesity significantly increases the risk of venous
thromboembolism, pre-eclampsia and gestational diabetes during pregnancy

Home situation
 Who lives with the patient?

 Do they feel well supported?

 Are there other children at home?

 Is the patient independent or do they require assistance?

 How is the pregnancy impacting on their ability to carry out activities of daily living?

 If receiving care input, what level are they requiring?

Occupation
 Ask about the patient’s current or previous occupation

 Ask about plans for maternity leave

Domestic abuse
 It is important to ask all pregnant women if they are a victim of domestic abuse (in privacy)

 This provides an opportunity for women to seek help

97
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. excessive vomiting in hyperemesis
gravidarum).

Choosing which symptoms to ask about depends on the presenting complaint, however, a selection of
potentially relevant systemic symptoms to an obstetric presentation are shown below.

Fever:

 Chorioamnionitis

 Urinary tract infection

Weight loss:

 Hyperemesis gravidarum

 Malignancy

Respiratory:

 Dyspnoea (secondary to pulmonary embolism or anaemia)

Gastrointestinal:

 Abdominal pain (secondary to placental abruption)

 Vomiting (secondary to hyperemesis gravidarum)

Urinary:

 Frequency, dysuria and urgency (secondary to urinary tract infection)

Musculoskeletal:

 Pelvic pain (secondary to symphysis pubis dysfunction)

Dermatology:

 A pigmented line on abdomen (linea nigra)

98
TAKING A SEXUAL HISTORY
Posted by Dr Anna Birtles and Dr Lewis Potter | Communication skills, History taking, Sexual Health

99
Table of Contents
We’d really appreciate if you could leave us a rating
Taking a sexual history is a key skill that all medical students need to learn. This guide discusses what
questions need to be asked and how they can be phrased when taking a sexual history.

It is really important to make sure you clarify the language the patient uses. “Sex” is not synonymous with
penetration, and personal preference over descriptive words for genitals should be acknowledged where
possible and appropriate. You also need to be aware of the array of social issues which you may come across
during the process of taking a sexual history (e.g. age of patient/partner(s), alcohol or drug intoxication,
partner notification, consent).

Check out the sexual history taking mark scheme here.

Opening the consultation


Introduce yourself – explaining your name and role

Confirm the patient’s details – name and date of birth

Explain the need to take a sexual history:

100
 “Today I need to take a sexual history from you, this is going to involve me asking some personal questions.
We ask these questions to accurately assess your risk of specific sexually transmitted infections, so please
don’t take any of the questions personally. Everything you tell me is confidential within the boundaries of
the team looking after your care. If however, we felt you or someone else was in significant danger, we
might have to break this confidentiality, to prevent harm. If you would prefer not to answer a particular
question or you’d like to stop the consultation at any point, please let me know.”

Gain consent:

 “Is it ok for me to ask you some initial questions?”

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

 “So what’s brought you in today?”


 “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?”

Things to ask people with a vagina


Symptoms
We have included a focused list of the key symptoms to ask people with a vagina, followed by some
background information on each, should you want to know a little more.

101
Key symptoms to ask about
 Genital skin changes
 Vulval itching or soreness
 Dysuria
 Abnormal vaginal discharge
 Abnormal vaginal bleeding
 Dyspareunia
 Abdominal or pelvic pain
 Systemic symptoms (e.g. malaise, fever)

Key questions to ask about each symptom


If any of the symptoms above are present, you need to clarify the following details about each of them:

 Onset – “When did the symptom start?”


 Duration – “How long did the symptom last for?”
 Severity – “How severe is the symptom?”
 Course – “Is the symptom worsening, improving, or continuing to fluctuate?”
 Intermittent vs continuous – “Is the symptom always present or does it come and go?”
 Exacerbating factors – “Are there any obvious triggers for the symptom?”
 Relieving factors – “Does anything improve the symptom?”
 Associated features – “Are there other symptoms that appear associated?” (e.g. fever/malaise)
 Previous episodes – “Have you had this symptom previously?”

Pain
If the symptom is pain, you should use the SOCRATES structure for gaining further details:

Site – “Where is the pain?”

Onset:

 “When did it start?”

 “Was the onset sudden or gradual?”

Character:

 “Is the pain sharp or a dull ache?”

 “Is the pain intermittent or continuous?”

Radiation – “Does the pain radiate anywhere?”

102
Associated symptoms – “Are there any other symptoms associated with the pain?”

Time course – “What is the overall time course of the pain?” (e.g. worsening, improving, fluctuating)

Exacerbating or relieving factors – “Does anything make the pain worse or better?”

Severity – “On a scale of 0-10, how severe is the pain, if 0 is no pain and 10 is the worst pain you’ve ever
experienced?”

Vaginal discharge
All healthy women will have some degree of regular vaginal discharge, so it is important to distinguish
between normal and abnormal vaginaldischarge when taking a sexual health history.

You should ask if the patient has noticed any changes to the following characteristics of
their vaginal discharge:

 Volume – “Have you noticed any change in the amount of vaginal discharge?”
 Colour (e.g. green, yellow or blood-stained) – “Have you noticed any change in the colour of your
discharge?”
 Consistency (e.g. thickened or watery) – “Have you noticed that your discharge has become more watery or
thickened recently?”
 Smell – “Have you noticed any change in the smell of the vaginal discharge?”

Several STIs can cause abnormal vaginal discharge:

 Gonorrhoea and chlamydia commonly present with abnormal vaginal discharge.


 Bacterial vaginosis typically presents with an offensive, fishy-smelling vaginal discharge, without any
associated soreness or irritation.
 Trichomonas vaginalis typically presents with yellow frothy discharge with associated vaginal itching and
irritation.

Vaginal bleeding
Abnormal vaginal bleeding is an important symptom that can be relevant to a wide range of
gynaecological disease.

Post-coital bleeding:

 Post-coital bleeding refers to vaginal bleeding occurring after sexual intercourse.

103
 Potential causes include infection (e.g. chlamydia and gonorrhoea), cervical ectropion and cervical cancer.

Intermenstrual bleeding:

 Intermenstrual bleeding refers to vaginal bleeding occurring between menstrual periods.

 Potential causes include infection (e.g. chlamydia and gonorrhoea), malignancy (e.g. cervical or endometrial
cancer), uterine fibroids, endometriosis, hormonal contraception (e.g. Mirena coil) and pregnancy.

Questions to ask:

 “Have you noticed any vaginal bleeding after sex?”

 “Have you noticed any vaginal bleeding between your periods?”

Dyspareunia
Dyspareunia refers to pain that occurs during sexual intercourse. It has several causes including sexually
transmitted infections (gonorrhoea and chlamydia), endometriosis, vaginal atrophy and malignancy.

The location of the pain can vary:

 Superficial dyspareunia – pain at the external surface of the genitalia (e.g. genital herpes)

 Deep dyspareunia – pain deep in the pelvis (more common with gonorrhoeal or chlamydial infection)

You should clarify the following details about the dyspareunia:

 Duration and timing of the symptom:

 “Do you ever experience any pain around the time of sex?”
 “How long does it last?”
 “When does it occur?” (before/during/after)
 Location of the pain (e.g. superficial or deep) – “Does the pain feel to be within the vagina, or deep in your
abdomen?”
 Nature of the pain (e.g. sharp, aching, burning) – “What kind of pain do you experience?”

Dysuria
Dysuria can be a symptom of a simple urinary tract infection, but may also indicate an underlying sexually
transmitted infection such as chlamydia, gonorrhoea, trichomoniasis or herpes.

Questions to ask:

 “Do you have any pain or stinging when passing urine?”

104
 “Do you feel you are passing urine more often?”

Vulval itching/soreness
Vulval itching and soreness are common symptoms which can be caused by a wide range of underlying
pathology including:

 Candida (thrush)
 Bacterial vaginosis
 Genital herpes
 Chlamydia
 Gonorrhoea
 Vaginal atrophy occurs in post-menopausal women and can lead to itching and bleeding of the vagina
 Lichen sclerosis appears as white patches on the vulva and is associated with itching
Questions to ask:

 “Do you have any itching down below?”


 “Have you noticed any recent vaginal soreness?”

Genital skin changes


Genital skin changes can occur secondary to several sexually transmitted diseases including:

 Genital herpes – painful crops of blisters/ulcers (vagina and cervix)


 Genital warts – non-painful lesions that can be located on the labia, clitoris, urethral meatus, introitus,
vagina, cervix, perineum, perianal area and anal canal.
Questions to ask:

 “Have you noticed any skin changes around your vagina?”


 “Have you noticed any blisters, spots or ulcers around your vagina or anus?”
Abdominal or pelvic pain
Abdominal and pelvic pain has many possible causes, but in the context of sexual health, pelvic
inflammatory disease (PID) secondary to chlamydia or gonorrhoea is relatively common. Another cause of
abdominal pain not to be missed in females is an ectopic pregnancy. The acronym SOCRATES, shown above,
provides a useful framework for asking about pain in a structured manner to help narrow the differential
diagnosis.

Systemic symptoms
Sexually transmitted infections can also cause systemic symptoms such as:
105
 Fever (secondary to pelvic inflammatory disease)

 Malaise

 Weight loss (e.g. HIV)

 Rash

 Swelling of large joints, conjunctivitis and cervicitis (Reiter’s syndrome secondary to chlamydia)
Questions to ask:

 “Have you felt feverish at all recently?”

 “Have you noticed any rashes elsewhere on your body?”


 “Do you have any swelling or pain in your joints?”

Menstrual history
A menstrual history involves clarifying the details of a woman’s menstrual cycle.

Menstrual cycle details


Duration:

 “How long do your periods typically last?”

Frequency:

 “How often do your periods happen?”


 “Are they regular and predictable?”

Menstrual blood flow:

 “Are your current periods heavier than your usual periods?”


 “Have you been flooding through sanitary towels?”
 “Have you been passing blood clots larger than a 10p coin?”
 “Do you experience a lot of pain during your periods?”

 “Are the heavy periods impacting your day to day life?”

Past gynaecological history


Cervical screening (known previously as the cervical smear):

 Confirm the date of the last cervical screening test


106
 Confirm the result of the last cervical screening test
 Ask if the patient received any treatment if the cervical screening test was abnormal and check if follow up
is in place

Previous gynaecological diagnoses and treatments:

 Ectopic pregnancy
 Sexually transmitted infections
 Endometriosis
 Malignancy (e.g. cervical, endometrial, ovarian)

Obstetric history
Current pregnancy (if relevant):

 Gestation
 Complications (e.g. small for gestational age)
 Fetal movements – check they are normal if at an appropriate gestation

Things to ask people with a penis


To avoid repetition, for each of the following symptoms, you should apply the same questions shown in the
previous “Key questions to ask about each symptom” section.

Symptoms
We have included a focused list of the key symptoms to ask people with a penis, followed by some
background information on each of the symptoms, should you want to know a little more.

Key symptoms to ask about


 Testicular pain or swelling
 Itching or sore skin
 Skin lesions (anogenital region)
 Urethral discharge
 Dysuria
 Systemic symptoms (e.g. malaise, fever)

107
Testicular pain and/or swelling
Testicular pain and swelling may suggest a diagnosis of epididymo-orchitis, which is often secondary to
chlamydia or gonorrhoea.

Questions to ask:

 “Have you noticed any pain in your testicles?” (clarify the details of the pain using the SOCRATES method
mentioned previously)
 “Have you noticed any change in the size of your testicles?”

Itching and/or sore skin


Itching and sore skin in the genital region may be caused by infection with candida, herpes simplex virus or
genital warts.

Questions to ask:

 “Have you noticed any itching around your genitals?”


 “Is the skin around your penis and/or testicles sore?”
 “Is the head of your penis sore?”

Skin lesions (anogenital region)


The most common causes of new skin lesions in the anogenital region are genital warts (HPV) and herpes
simplex. Genital warts are typically painless, however, patients sometimes can experience itching and
bleeding. Genital herpes simplex lesions typically present as crops of painful blisters/ulcers in the genital
area (including the urethra).

Questions to ask:

 “Have you noticed any lumps, bumps or ulcers around your penis, testicles or anus?”
 “Are the lesions itchy or painful?”

 “Have you noticed any tingling or burning in the area of the lesions?”

Urethral discharge
Urethral discharge may suggest underlying chlamydial or gonorrhoeal infection.

Questions to ask:

 “Have you noticed any discharge from your penis?”

108
Dysuria (including frequency, urgency, nocturia)
Dysuria can be a symptom of a simple urinary tract infection, but may also indicate an underlying sexually
transmitted infection such as chlamydia, gonorrhoea or herpes.

Questions to ask:

 “Do you have any pain or burning in your genitals when you pass urine?”
 “Do you feel you are passing urine more often?”
 “Is there any blood in your urine?”

Systemic symptoms
Sexually transmitted infections can also cause systemic symptoms such as:

 Fever (secondary to pelvic inflammatory disease)

 Malaise

 Weight loss (e.g. HIV)

 Rash

 Swelling of large joints, conjunctivitis and cervicitis (Reiter’s syndrome secondary to chlamydia)

Questions to ask:

 “Have you felt feverish at all recently?”

 “Have you noticed any rashes elsewhere on your body?”


 “Do you have any swelling or pain in your joints?”

Sexual history: Last sexual contact


Sign-posting
Sign-posting here is of benefit to ensure the patient is prepared for the nature of the questions surrounding
their sexual history.

 “Next, I’m going to move on to discuss your sexual history, some of these questions are quite in-depth and
personal. The reason we ask these questions is so that we can accurately assess the risk of sexually

109
transmitted infections. We ask the same questions to everyone, so please don’t take anything personally. If
you feel uncomfortable and would prefer not to answer, just let me know.”

Timing
Ask about the timing of the last sexual contact:

 “When did you last have a sexual encounter?”

Consent
Ask if the patient feels this sexual encounter occurred with their consent:

 “Was this sexual encounter consensual?”

Relationship
Ask if this was a regular sexual partner or a one-off casual sexual encounter:

 “Was this a regular sexual partner, or a casual sexual encounter?”

Partner demographics
Clarify the sex and country of origin of the partner:

 “What sex was the partner in question?”


 “What country was the partner from?”

Types of sex involved


You should clarify what type of sex was involved in the encounter (e.g. oral, vaginal, anal):

 “What type of sex was involved in this sexual encounter?”


 “Did you give or receive oral sex?”

 “Did you have vaginal sex?”

 “Did you give or receive anal sex?”

Contraception
Clarify the type of contraception used and the consistency of usage:

110
 “Did you use any form of contraception for the sexual encounter?”

 “Was any barrier contraception used during sex?”

 “Was there any issues with the contraception used?” (e.g. condom splitting)
 “Was there any point at which contraception was not used during the sex?”
 “Did you use contraception for every sexual encounter with this individual?”

Other sexual partners


Ask about other sexual partners in the last 3 months:

 “Have you had any other partners within the last 3 months?” – if so, repeat the above for each

Past medical and surgical history


Medical or surgical problems:

 “Do you have any medical conditions?”

 “Is there anything you see the doctor regularly for?”


 “Have you been in a hospital for anything in the past?”
Previous sexually transmitted infections (including partners)

Drug history
Current medications:

 “Do you take any regular medications?”

Recent antibiotics:

 “Have you taken any recent antibiotics?”


111
Allergies:

 “Do you have any allergies?”

Social history
Smoking:

 How many cigarettes a day?

 How long have they smoked for?

Alcohol:

 How many units a week?

 Clarify the type, volume and strength of the alcohol

Recreational drugs:

 Clarify the types of recreational drugs used

 IV drug administration and sharing of the equipment used to snort cocaine increases the risk of acquiring
blood-borne viruses such as Hepatitis C and HIV

Also consider if it is appropriate to ask the age of partner(s), and be aware of safeguarding issues, especially
surrounding the social factors related to sexual encounters.

HIV risk history


112
Identify if positive risk factors are present:

 “Have you ever had a partner who is known to be HIV positive?”


 “Have you ever had sex with a bisexual man/engaged in male homosexual activity?”
 “Have you ever had sex with someone abroad, or who was born in a different country?”
 “Have you ever injected drugs?”
 “Are you aware of any of your previous partners having ever injected drugs?”
 “Have you ever paid someone for sex, or been paid for sex?”

STROKE AND TIA HISTORY TAKING


113
Posted by Francine Cheese | History taking

Table of Contents
We’d really appreciate if you could leave us a rating
Being able to take a thorough history of a transient ischaemic attack (TIA) or stroke 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 history. Check out the
stroke and TIA history taking mark scheme here.

TIAs and strokes both occur when the blood supply to the brain is interrupted. The difference occurs in the
definition of the timing: A stroke produces symptoms that last for at least 24 hours, whereas symptoms
produced by a TIA are transient (less than 24 hours), usually resolving fully within 30 minutes.

HPC
PAST MEDICAL HX
DRUG HX
FAMILY HX
SOCIAL HX
SYSTEMIC ENQUIRY
CLOSING THE CONSULTATION
MARK SCHEME (PDF)

Opening the consultation


Introduce yourself – name/role

114
Confirm patient details – name/DOB

Explain the need to take a history

Gain consent

Ensure the patient is comfortable

A collateral history is often very valuable in the context of suspected stroke or TIA, particularly when the
patient is unable to communicate effectively.

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 you mean by ‘funny turn?”

In the context of stroke/TIA it’s also important to pay attention to how the patient is
communicating:

 Do they have good articulation?

 Is there evidence of dysphasia?

 Is there evidence of dysarthria?

History of presenting complaint


Due to the nature of TIAs and strokes, it may be useful to first ask some orientation questions, such as the
patient’s age, the month and what they believe your job role to be. This can enable you to quickly establish if
the patient is orientated and help gauge how reliable the history is likely to be.

Onset of symptom(s):

 When did the symptom start? (date and time)

115
 Was the onset acute or gradual?

 It is essential to get an accurate onset time of symptoms:

 This can help differentiate between TIA and stroke as discussed above

 If the patient is having an ischaemic stroke then this information is key in deciding if they are within the
therapeutic window for thrombolysis

 If a patient has woken up with symptoms (but had none before going to sleep) the onset time is assumed to
be when they went to sleep

Duration of symptom(s): minutes/hours/days/weeks/months/years

Severity:

 Weakness: Try to clarify how weak (e.g. subtle, moderate, complete paralysis)

 Sensory disturbance: Was the arm completely numb or did it just feel different to normal?

 Visual disturbance: How much of the vision was affected? Was vision blurred or completely lost?

 Expressive dysphasia: Was the patient able to speak at all?

 Receptive dysphasia: Was the patient able to understand any communication?

 Dysarthria: Was the patient’s speech mildly slurred or incomprehensible?

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: Was there any obvious triggers for the symptom?

Relieving factors: Does anything appear to improve the symptom?

Associated features: Are there other symptoms that appear associated? (e.g.
headache/nausea/vomiting/neck stiffness)

Previous episodes:

 Has the patient experienced this symptom previously?

 How many previous episodes?

 What frequency?

Ask the patient what their dominant hand is (useful to know before clinical examination)

116
Ask about any recent head or neck trauma (important if considering intracranial bleeding or carotid
dissection)

Key stroke and TIA symptoms


Weakness
 Onset and duration of weakness?

 Location of the weakness? (e.g. lower limb, upper limb, face)

 Severity of the weakness? (e.g. subtle, struggling with holding a cup, completely flaccid)

 Mobility: Is the patient still able to independently mobilise?

 Is the weakness getting worse or better?

Sensory disturbance
 Onset and duration of sensory disturbance?

 Location of the sensory disturbance?

 Severity of sensory disturbance? (e.g. completely numb, tingling, feeling slightly different)

Visual disturbance
 Onset and duration of visual disturbance?

 Type of visual disturbance? (e.g. vertigo/heminopia/quadrantopia/amaurosis fugax)

Co-ordination problems
 Does the patient feel their balance is poor?

 Are they bumping into walls and door frames? (also consider visual field loss)

 Does the patient think any of their limbs feels more clumsy?

 Is the patient experiencing vertigo? (room spinning around them)

Speech disturbance
 Clarify type of speech disturbance:

 Expressive dysphasia “I knew what I wanted to say, but I couldn’t get it out”
117
 Receptive dysphasia “I wasn’t able to understand anyone, they were speaking jibberish”

 Dysarthria “My speech was really slurred, it sounded like I was drunk”

Swallowing problems (dysphagia)


 Has the patient has noticed any problems swallowing fluids or food? (e.g. coughing/choking)

 Dysphagia is common in stroke and if not recognised can lead to aspiration pneumonia and choking

Headache
 Has the patient experienced headache during this episode?

 Did the headache start before or after the onset of other symptoms?

 Clarify the type of headache:

 Thunderclap – subarachnoid haemorrhage

 Unilateral – consider migraine (hemiplegic migraine is a stroke mimic)

 Generalised headache worse when lying down – consider raised intracranial pressure (e.g. haemorrhagic
stroke)

Nausea/vomiting
 In the context of stroke consider either raised intracranial pressure (e.g. haemorrhagic stroke) or posterior
circulation ischaemic stroke (POCS)

Reduced level of consciousness


 Consider raised intracranial pressure (e.g. haemorrhagic stroke or malignant middle cerebral artery
syndrome)

 Consider seizures which can occur in the context of haemorrhagic strokes and ischaemic strokes

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

 Site: Where is the pain?


 Onset: When did it start? / Sudden or gradual?

118
 Character: Sharp / dull ache / burning
 Radiation: Does the pain move anywhere else?
 Associations: Are there any other symptoms associated with the pain?
 Time course: Worsening / improving / fluctuating / time of day dependent
 Exacerbating/Relieving factors: Anything make the pain better or worse?
 Severity: On a scale of 0-10, how severe is the pain?

Major stroke risk factors


 Ischaemic heart disease

 Hypertension

 Atrial fibrillation

 Hypercholesterolaemia

 Diabetes

 Previous stroke or TIA

 Smoking

 Excessive alcohol intake

 Family history of stroke in first-degree relatives

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.

119
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, a bit about health conditions
in your family, your day to day life, and your medications”

Past medical history


Stroke risk factors:

 Ischaemic heart disease

 Hypertension

 Atrial fibrillation

 Hypercholesterolaemia

 Diabetes

 Previous stroke or TIA

 Smoking

 Excessive alcohol intake

 Hypercoagulable disease (e.g. sickle cell anaemia, polycythemia vera)

 Prosthetic heart valves

 Carotid stenosis

 Poor ventricular function

 Migraine with aura

Previous stroke or TIA:

120
 Check when the episodes occurred and what deficits the patient developed (e.g. sensory disturbance,
weakness, visual disturbance)

 Clarify what investigations they underwent and what treatment they received

 Ask about residual deficits (e.g. after stroke) as it is useful to know the patient’s baseline function to
accurately interpret current clinical findings

Previous similar episodes – clarify frequency of episodes and symptoms experienced

Other neurological conditions – useful to be aware of as the patient may have pre-existing neurological
deficits as a result (e.g. multiple sclerosis)

Recent trauma to the head or neck – useful when considering intracranial bleeding and carotid dissection

Other medical conditions – clarify what other medical conditions the patient has, as they may be relevant
when considering treatment options for stroke or TIA

Surgical history:

 Neurosurgery

 Carotid surgery

 Cardiac surgery (e.g. valve replacement)

Drug history
Antiplatelets or anticoagulant medication:

 Aspirin

 Clopidogrel

 Warfarin

 Apixaban

 Rivaroxaban

 Dabigatran

Other regular medications:


121
 Antihypertensives

 Cholesterol-lowering agents (e.g. statins)

 Combined oral contraceptive pill

ALLERGIES – document these clearly

Family history
Stroke or TIA in first-degree relatives?

Cardiovascular disease in first-degree relatives?

Clarify the age at which these conditions affected the patient’s family member

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 – e.g. cocaine/amphetamines

Diet

Exercise – baseline level of the patient’s day to day activity

Living situation:

 Type of accommodation – adaptations/stairs


 Who lives with the patient?

 Is the patient supported at home?

Activities of daily living:

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


122
 Can they manage self-hygiene/housework/food shopping?

 Does the patient have any carer input? (clarify the level of care)

 Does the patient use any mobility aids? (e.g. stick/wheelchair/frame)

Occupation – important to be aware of as the stroke or TIA may have implications on their ability to work
safely (e.g. if they drive for work/works at height)

Driving status:

 If the patient drives then a TIA or stroke may result in temporary or permanent restrictions on their ability
to continue driving (this will depend on the clinical features of the episode and residual deficits)

 Clarify the type of vehicle the patient drives, as heavy goods vehicles (HGVs) have different requirements

Systemic enquiry
A thorough history will also include a systemic enquiry. This can be helpful when considering other possible
causes for the patient’s presentation (e.g. infections, inner ear problems, psychomotor problems,
hypoglycaemia, seizures and cardiac syncope). It can also pick up on other problems the patient might be
experiencing. 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 / Abdominal pain / Bowel habit / Weight loss
 Urinary – Volume of urine passed / Frequency / Dysuria / Urgency / Incontinence
 CNS – Anxiety/ Stress/ Headaches/ Weakness / Numbness/ Pain/ Tingling / Loss of consciousness/Confusion
 Musculoskeletal – Bone and joint pain / Muscular pain
 Dermatology – Rashes / Skin breaks / Ulcers / Lesions

123
LOSS OF CONSCIOUSNESS HISTORY TAKING – OSCE
GUIDE
Posted by Veronica Birca | Cardiology, History taking, Neurology

Table of Contents
We’d really appreciate if you could leave us a rating
Loss of consciousness occurs when the function of both cerebral hemispheres or the brainstem reticular
activating system is compromised. The two major causes of transient loss of consciousness, syncope and
seizures, can be easily confused. When taking a history for an episode of transient loss of consciousness, it is
important to keep in mind the different possible causes. Throughout the interview with the patient, narrow
the differential diagnosis by asking targeted questions. Check out the loss of consciousness history taking
mark scheme here.

HPC
PAST MEDICAL HX
DRUG HX
FAMILY HX
SOCIAL HX
SYSTEMIC ENQUIRY
CLOSING THE CONSULTATION
MARK SCHEME (PDF)

Causes of transient loss of consciousness


124
Syncope (caused by global cerebral hypoperfusion)
Reflex syncope (a.k.a. neurally mediated syncope)
Syncope associated with a sudden decrease in blood pressure and heart rate in response to a trigger.

Vasovagal syncope:

 Emotional distress: fear, pain, instrumentation, blood phobia, enclosed space


 Orthostatic stress: prolonged standing
Situational syncope: cough, sneeze, defecation, post-micturition, post-exercise, post-prandial

Carotid sinus hypersensitivity: triggered by sudden head turning, tight collar, shaving

Cardiovascular syncope
Loss of consciousness associated with decreased cardiac output.

Causes include:

 Arrhythmia

 Structural cardiovascular disease: coronary artery disease, valve disease, cardiac tamponade, hypertrophic
cardiomyopathy, aortic dissection
 Structural pulmonary disease: pulmonary embolism

Orthostatic hypotension
Syncope associated with a sudden drop in blood pressure after standing up.

Causes include:

 Hypovolaemia: haemorrhage, diarrhoea, vomiting


 Iatrogenic: beta-blockers, diuretics, alcohol, vasodilators, antidepressants, phenothiazines
 Autonomic failure: diabetic neuropathy, Parkinson’s disease, spinal cord injury

Seizure
Seizures are caused by abnormal excessive neuronal activity in the brain, leading to impairment of
normal cognitive function.

Seizures that involve a complete loss of consciousness are known as generalised seizures (either
convulsive or non-convulsive).

Causes
Metabolic disturbances – hypoglycaemia, electrolyte abnormalities, drug or alcohol intoxication, adrenal
insufficiency
125
Space-occupying lesions

Head trauma

Stroke

Medication – some medications lower the seizure threshold (e.g. Nefopam)

Epilepsy – spontaneous abnormal excessive neuronal activity in the brain

Opening the consultation


Introduce yourself – name/role

Confirm patient details – name/DOB

Ensure the patient is comfortable

Explain the need to take a history

Gain consent

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.” or “Can you explain what that pain was like?”

126
History of presenting complaint
Effective history taking is key to narrowing the differential diagnosis when the presenting complaint is loss
of consciousness. A collateral history provided by someone who witnessed the episode is often required to
gain accurate details about what happened during and after the loss of consciousness.

Before the loss of consciousness

Was there a trigger?


Reflex syncope is often associated with a trigger:

 Vasovagal syncope – emotional distress (fear, pain, instrumentation, blood phobia) // orthostatic stress
(prolonged standing)

 Situational syncope – cough, sneeze, defecation, post-micturition, post-exercise, post-prandial

 Carotid sinus hypersensitivity – shaving, tight-fitting collar, sudden head-turning

Physical exertion: cardiovascular syncope (e.g. aortic stenosis/arrhythmia)

Standing from sitting: orthostatic hypotension (e.g. hypovolaemia/autonomic failure)

Working with arms elevated above head: subclavian steal syndrome

Exposure to rapid flickering lighting: photosensitive epilepsy

Were there prodromal symptoms or an aura?


Vasovagal syncope is often preceded by prodromal symptoms:

 Progressive light-headedness

 Visual disturbances (dimming of vision or loss of vision)

 Weakness of the extremities

 Sweating

 Nausea

 Tinnitus

Seizures can also begin with subjective symptoms (called “epileptic auras”):

127
 Olfactory or gustatory hallucinations (specific smell/taste)

 Visual hallucinations (e.g. flashing lights/blurring of vision)

 Déjà-vu feeling

 Sensory disturbances (numbness/tingling/burning)

Cardiovascular syncope often lacks any prodromal symptoms, with the patient feeling ok and then
losing consciousness suddenly with no warning. You should, therefore, consider underlying
arrhythmia or structural heart disease if there is an absence of prodromal symptoms.

Were there any other symptoms occurring before the loss of consciousness?
 Focal motor or sensory deficits: suggestive of focal seizures that may have then progressed to a generalised
seizure (causing loss of consciousness)
 Palpitations: arrhythmia
 Chest pain: myocardial infarction / pulmonary embolism / aortic dissection
 Slow controlled collapse towards the ground is typical of vasovagal syncope

Whilst the patient was unconscious

Motor
Flaccidity: cerebral hypoperfusion

Initial tonic stiffening, followed by clonic (jerking) movements of the extremities: generalized tonic-
clonic seizures

Cerebral hypoperfusion can also result in stiffening or jerking movements.

Duration
Syncope: <20 seconds typically

Seizure: often longer than 20 seconds

Other
Tongue biting (lateral aspect): generalized tonic-clonic seizure

128
Urinary or faecal incontinence: more common in seizure than syncope

Cyanosis (caused by cardiorespiratory arrest): arrhythmia/structural cardiac disease/pulmonary


embolism

Cyanosis can also occur in a prolonged seizure, but tonic-clonic movements precede cyanosis.

After the loss of consciousness

How long did it take for full recovery?


Syncope: rapidly regains full lucidity (within 20-30 seconds)

Seizure: post-ictal period of confusion and/or agitation lasting several minutes to hours (often not recalled
by the patient)

Were there any relieving factors?


Seated or supine position: orthostatic hypotension

Other questions
Ask about any secondary injuries as a result of the loss of consciousness

Past medical history


Syncope – clarify type of syncope, triggers, frequency and last event

Epilepsy/febrile seizures – clarify frequency, treatment and last event

Hypertension, hypercholesterolemia, coronary artery disease, arrhythmia (all relevant to


cardiovascular syncope)

Parkinson’s disease/diabetes (orthostatic hypotension)

Head trauma (increased risk of seizures)

Pacemaker (cardiovascular syncope) – also useful to know, as this can be interrogated to look for
arrhythmias at the time of the event

Recent surgery (increased risk of pulmonary embolism)

Patients with syncope and heart disease are at a markedly increased risk for ventricular tachycardia and
sudden death.

129
Drug history
Oral/subcutaneous hypoglycaemic agents (hypoglycaemia)

Anticonvulsants (check if patient has been taking these as prescribed)

Beta-blockers (bradycardia/hypotension)

Diuretics and antihypertensive agents (orthostatic hypotension)

Tricyclic amines (orthostatic hypotension and seizures)

Short-acting benzodiazepines (seizures upon withdrawal)

Anti-inflammatory agents (syncope secondary to gastrointestinal haemorrhage)

Oral contraceptives (pulmonary embolism)

Recent changes (e.g. cessation of corticosteroid therapy potentially leading to adrenal insufficiency)

Compliance (e.g. inadequate administration of insulin in diabetes could lead to hypoglycemia)

Family history
Cardiovascular disease (structural cardiac disease/arrhythmias/channelopathies)

Epilepsy

Diabetes

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

Alcohol – How many units a week? – be specific about type/volume/strength of alcohol (seizures caused by
withdrawal/intoxication)

130
Level of functional independence:

 It’s important to understand the patient’s care needs, as this will influence how you manage them

 Understanding the patient’s daily activities also allows you to consider the risk posed by further episodes of
loss of consciousness

Occupation:

 Check what their job involves, as they may need to be advised to take time off work until a diagnosis is
established (e.g. someone working at heights)

Driving:

 Depending on the suspected diagnosis there may be restrictions that result in temporary driving
suspension (e.g. seizure)

 You should also check the kind of vehicle operated, as heavy goods vehicles often have different rules

Systemic enquiry
Systemic enquiry involves performing a brief screen for symptoms in other body systems, that are not
directly linked to the patient’s presenting complaint, but may, however, be relevant to the diagnosis.

Choosing which symptoms to ask about varies depending on the patient characteristics and his
presenting complaint.

Cardiovascular – Chest pain (myocardial ischemia) / Back pain (aortic dissection) / Palpitations
(arrhythmias)

Respiratory – Dyspnoea (pulmonary embolism)

Gastrointestinal – Sudden abdominal pain (aortic aneurysm rupture/pancreatitis)

Neurological – Weakness / Sensory disturbance / Visual disturbance

131
Musculoskeletal – Joint/bone pain (fractures secondary to fall)

BREAST LUMP HISTORY


Posted by Dr Lewis Potter | History taking

132
Table of Contents
We’d really appreciate if you could leave us a rating
Being able to take a breast lump history 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 breast lump history. Check out the breast lump history 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

133
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


Questions to ask about the lump
Size – Has it changed? / Over what duration?

Onset – When did they first notice the lump?

Is the lump painful? – ask SOCRATES (shown below)

Is the lump’s size or discomfort related to the menstrual cycle in any way?

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?
134
 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?
Local associated symptoms
Nipple discharge or bleeding?

Nipple inversion? – Is this new or has it always been the case?

Skin changes overlying the lump or elsewhere on the breast?

 Eczema
 Dimpling
 Ulceration

Systemic symptoms
Weight loss

Fever

Lethargy

Pain elsewhere – e.g. spine / axilla / abdomen

Gland swelling – lymphadenopathy

Other questions
Has the patient ever experienced similar symptoms in the past?

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

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

Duration – Days / Weeks / Months / Years

Severity – i.e. How much is the given symptom impacting on their life?

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

135
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 breast lump and your concerns regarding it”
 What you plan to cover next – “Now I’d like to discuss your past medical history and your medications”

Past medical history


Relevant obstetric/gynaecological history:

 Age at menarche/menopause

136
 Parity

 Age at first pregnancy

 Did they breastfeed?

 Use of hormonal replacement therapy or oral contraceptive pill

Relevant past medical history:

 Recent breast trauma – fat necrosis


 Previous breast disease – malignant or benign?
 Any other previous malignancies?

 Other significant medical problems?

Surgical history – breast surgery / other surgery

Drug history
Relevant prescribed medication:

 Oral contraceptive pill

 Hormonal replacement therapy

Other regular medications

Over the counter drugs

Herbal remedies

ALLERGIES – ensure to document these clearly

137
Family history
Family history of breast disease – consider BRCA mutations

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

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

Recreational drug use?

Living situation:

 Do they have accommodation?

 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?

 Is the symptom impacting on their abilities to carry out daily activities?

Occupation – Is the patient currently coping at work? What are their expected duties?

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 in metastatic breast cancer).

138
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

139
LOSS OF CONSCIOUSNESS HISTORY TAKING – OSCE
GUIDE
Posted by Veronica Birca | Cardiology, History taking, Neurology

Table of Contents
We’d really appreciate if you could leave us a rating
Loss of consciousness occurs when the function of both cerebral hemispheres or the brainstem reticular
activating system is compromised. The two major causes of transient loss of consciousness, syncope and
seizures, can be easily confused. When taking a history for an episode of transient loss of consciousness, it is
important to keep in mind the different possible causes. Throughout the interview with the patient, narrow
the differential diagnosis by asking targeted questions. Check out the loss of consciousness history taking
mark scheme here.

HPC
PAST MEDICAL HX
DRUG HX
FAMILY HX
SOCIAL HX
SYSTEMIC ENQUIRY
CLOSING THE CONSULTATION
MARK SCHEME (PDF)

Causes of transient loss of consciousness


140
Syncope (caused by global cerebral hypoperfusion)
Reflex syncope (a.k.a. neurally mediated syncope)
Syncope associated with a sudden decrease in blood pressure and heart rate in response to a trigger.

Vasovagal syncope:

 Emotional distress: fear, pain, instrumentation, blood phobia, enclosed space


 Orthostatic stress: prolonged standing
Situational syncope: cough, sneeze, defecation, post-micturition, post-exercise, post-prandial

Carotid sinus hypersensitivity: triggered by sudden head turning, tight collar, shaving

Cardiovascular syncope
Loss of consciousness associated with decreased cardiac output.

Causes include:

 Arrhythmia

 Structural cardiovascular disease: coronary artery disease, valve disease, cardiac tamponade, hypertrophic
cardiomyopathy, aortic dissection
 Structural pulmonary disease: pulmonary embolism

Orthostatic hypotension
Syncope associated with a sudden drop in blood pressure after standing up.

Causes include:

 Hypovolaemia: haemorrhage, diarrhoea, vomiting


 Iatrogenic: beta-blockers, diuretics, alcohol, vasodilators, antidepressants, phenothiazines
 Autonomic failure: diabetic neuropathy, Parkinson’s disease, spinal cord injury

Seizure
Seizures are caused by abnormal excessive neuronal activity in the brain, leading to impairment of
normal cognitive function.

Seizures that involve a complete loss of consciousness are known as generalised seizures (either
convulsive or non-convulsive).

Causes
Metabolic disturbances – hypoglycaemia, electrolyte abnormalities, drug or alcohol intoxication, adrenal
insufficiency
141
Space-occupying lesions

Head trauma

Stroke

Medication – some medications lower the seizure threshold (e.g. Nefopam)

Epilepsy – spontaneous abnormal excessive neuronal activity in the brain

Opening the consultation


Introduce yourself – name/role

Confirm patient details – name/DOB

Ensure the patient is comfortable

Explain the need to take a history

Gain consent

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.” or “Can you explain what that pain was like?”

142
History of presenting complaint
Effective history taking is key to narrowing the differential diagnosis when the presenting complaint is loss
of consciousness. A collateral history provided by someone who witnessed the episode is often required to
gain accurate details about what happened during and after the loss of consciousness.

Before the loss of consciousness

Was there a trigger?


Reflex syncope is often associated with a trigger:

 Vasovagal syncope – emotional distress (fear, pain, instrumentation, blood phobia) // orthostatic stress
(prolonged standing)

 Situational syncope – cough, sneeze, defecation, post-micturition, post-exercise, post-prandial

 Carotid sinus hypersensitivity – shaving, tight-fitting collar, sudden head-turning

Physical exertion: cardiovascular syncope (e.g. aortic stenosis/arrhythmia)

Standing from sitting: orthostatic hypotension (e.g. hypovolaemia/autonomic failure)

Working with arms elevated above head: subclavian steal syndrome

Exposure to rapid flickering lighting: photosensitive epilepsy

Were there prodromal symptoms or an aura?


Vasovagal syncope is often preceded by prodromal symptoms:

 Progressive light-headedness

 Visual disturbances (dimming of vision or loss of vision)

 Weakness of the extremities

 Sweating

 Nausea

 Tinnitus

Seizures can also begin with subjective symptoms (called “epileptic auras”):

143
 Olfactory or gustatory hallucinations (specific smell/taste)

 Visual hallucinations (e.g. flashing lights/blurring of vision)

 Déjà-vu feeling

 Sensory disturbances (numbness/tingling/burning)

Cardiovascular syncope often lacks any prodromal symptoms, with the patient feeling ok and then
losing consciousness suddenly with no warning. You should, therefore, consider underlying
arrhythmia or structural heart disease if there is an absence of prodromal symptoms.

Were there any other symptoms occurring before the loss of consciousness?
 Focal motor or sensory deficits: suggestive of focal seizures that may have then progressed to a generalised
seizure (causing loss of consciousness)
 Palpitations: arrhythmia
 Chest pain: myocardial infarction / pulmonary embolism / aortic dissection
 Slow controlled collapse towards the ground is typical of vasovagal syncope

Whilst the patient was unconscious

Motor
Flaccidity: cerebral hypoperfusion

Initial tonic stiffening, followed by clonic (jerking) movements of the extremities: generalized tonic-
clonic seizures

Cerebral hypoperfusion can also result in stiffening or jerking movements.

Duration
Syncope: <20 seconds typically

Seizure: often longer than 20 seconds

Other
Tongue biting (lateral aspect): generalized tonic-clonic seizure

144
Urinary or faecal incontinence: more common in seizure than syncope

Cyanosis (caused by cardiorespiratory arrest): arrhythmia/structural cardiac disease/pulmonary


embolism

Cyanosis can also occur in a prolonged seizure, but tonic-clonic movements precede cyanosis.

After the loss of consciousness

How long did it take for full recovery?


Syncope: rapidly regains full lucidity (within 20-30 seconds)

Seizure: post-ictal period of confusion and/or agitation lasting several minutes to hours (often not recalled
by the patient)

Were there any relieving factors?


Seated or supine position: orthostatic hypotension

Other questions
Ask about any secondary injuries as a result of the loss of consciousness

Past medical history


Syncope – clarify type of syncope, triggers, frequency and last event

Epilepsy/febrile seizures – clarify frequency, treatment and last event

Hypertension, hypercholesterolemia, coronary artery disease, arrhythmia (all relevant to


cardiovascular syncope)

Parkinson’s disease/diabetes (orthostatic hypotension)

Head trauma (increased risk of seizures)

Pacemaker (cardiovascular syncope) – also useful to know, as this can be interrogated to look for
arrhythmias at the time of the event

Recent surgery (increased risk of pulmonary embolism)

Patients with syncope and heart disease are at a markedly increased risk for ventricular tachycardia and
sudden death.

145
Drug history
Oral/subcutaneous hypoglycaemic agents (hypoglycaemia)

Anticonvulsants (check if patient has been taking these as prescribed)

Beta-blockers (bradycardia/hypotension)

Diuretics and antihypertensive agents (orthostatic hypotension)

Tricyclic amines (orthostatic hypotension and seizures)

Short-acting benzodiazepines (seizures upon withdrawal)

Anti-inflammatory agents (syncope secondary to gastrointestinal haemorrhage)

Oral contraceptives (pulmonary embolism)

Recent changes (e.g. cessation of corticosteroid therapy potentially leading to adrenal insufficiency)

Compliance (e.g. inadequate administration of insulin in diabetes could lead to hypoglycemia)

Family history
Cardiovascular disease (structural cardiac disease/arrhythmias/channelopathies)

Epilepsy

Diabetes

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

Alcohol – How many units a week? – be specific about type/volume/strength of alcohol (seizures caused by
withdrawal/intoxication)

146
Level of functional independence:

 It’s important to understand the patient’s care needs, as this will influence how you manage them

 Understanding the patient’s daily activities also allows you to consider the risk posed by further episodes of
loss of consciousness

Occupation:

 Check what their job involves, as they may need to be advised to take time off work until a diagnosis is
established (e.g. someone working at heights)

Driving:

 Depending on the suspected diagnosis there may be restrictions that result in temporary driving
suspension (e.g. seizure)

 You should also check the kind of vehicle operated, as heavy goods vehicles often have different rules

Systemic enquiry
Systemic enquiry involves performing a brief screen for symptoms in other body systems, that are not
directly linked to the patient’s presenting complaint, but may, however, be relevant to the diagnosis.

Choosing which symptoms to ask about varies depending on the patient characteristics and his
presenting complaint.

Cardiovascular – Chest pain (myocardial ischemia) / Back pain (aortic dissection) / Palpitations
(arrhythmias)

Respiratory – Dyspnoea (pulmonary embolism)

Gastrointestinal – Sudden abdominal pain (aortic aneurysm rupture/pancreatitis)

Neurological – Weakness / Sensory disturbance / Visual disturbance

147
Musculoskeletal – Joint/bone pain (fractures secondary to fall)

PAEDIATRIC HISTORY TAKING


Posted by Dr Lewis Potter | History taking

148
Table of Contents
We’d really appreciate if you could leave us a rating
Paediatric history taking differs significantly from a standard history for a number of reasons, the first being
that the patient may not be able to communicate, so a collateral history is often essential. In addition, there
are a number of extra topics you’ll need to cover, such as immunisation and developmental history. Check out
the paediatric history taking mark schemehere.

HPC
PAST MEDICAL HX
DRUG HX
FAMILY HX
SOCIAL HX
SYSTEMIC ENQUIRY
INTERACTIVE MARK SCHEME
MARK SCHEME (PDF)

Opening the consultation


These questions may need to be addressed at the patient’s parents, depending on their age, so adjust as
appropriate.
149
Introduce yourself – name/role

Confirm patient details – name/DOB

Explain the need to take a history

Gain consent to take a history

Ensure the patient is comfortable

Presenting complaint
Give the patient time to explain the problem/symptoms they’ve been experiencing.

A paediatric history often relies on collateral information from the parents.

It’s important to use open questioning to elicit the patient’s or parent’s presenting complaint.

“So what’s brought your child in today?” or “What’s brought you in today?”

This can sometimes be difficult when talking to children and you may need to adopt an approach
involving more direct questioning. So instead of saying “Tell me about the pain” you may need to ask
a series of questions requiring only yes or no answers.

“Is the pain in your tummy?” “Is the pain in your back?”

Allow the patient time to answer and do not interrupt.

History of presenting complaint


Onset – when did the symptom start? / was the onset acute or gradual?

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

Severity – e.g. if the symptom is shortness of breath – are they able to talk in full sentences?

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

Intermittent or continuous? – is the symptom always present or does it come and go?
150
Precipitating factors – are there any obvious triggers for the symptom?

Relieving factors – does anything appear to improve the symptoms e.g. an inhaler

Associated features – are there other symptoms that appear associated e.g. fever/malaise

Previous episodes – has the patient experienced this symptom previously?

Key paediatric questions

 Feeding – volume of intake / frequency of feeding


 Vomiting – frequency / volume / timing – projectile? / bilious? / blood?
 Fever – confirmed using thermometer vs subjectively feeling hot?
 Wet nappies / urine output – number of wet nappies a day – ↓ in dehydration
 Stools – consistency / steatorrhoea? (biliary obstruction) / red currant jelly (intussusception)
 Rash – any obvious trigger? / distribution? / blanching?
 Behaviour – irritability / less responsive
 Cough – productive? / associated increased work of breathing?
 Rhinorrhoea – often associated with viral upper respiratory disease
 Weight gain or loss – check baby book if the parent has it with them
 Sleeping pattern – more sleepy than usual?
 Unwell contacts – often children become infected from unwell siblings
 Localising symptoms – tugging at an ear/ holding tummy

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

 Site – where exactly is the pain / where is the pain worst


 Onset – when did it start? / did it come on suddenly or gradually?
 Character – what does it feel like? (sharp stabbing / dull ache / burning)
 Radiation – does the pain move anywhere else?
 Associations – any other symptoms associated with the pain
 Time course – does the pain have a pattern (e.g. worse in the mornings)
 Exacerbating/relieving factors – does anything make it particularly worse or better?
 Severity – on a scale of 0-10, with 0 being no pain and 10 being the worst pain you’ve ever felt

Ideas, Concerns and Expectations – often addressed to parents


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

151
Concerns – explore any worries the patient/parent may have regarding the symptoms

Expectations – gain an understanding of what the patient/parent is hoping to achieve from the consultation

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

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

It also allows the patient/parent to correct any inaccurate information and expand further on certain
aspects.

Once you have summarised, ask the patient/parent 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/parent:

 What you have covered – “Ok, so we’ve talked about the symptoms”
 What you plan to cover next – “Now I’d like to discuss any previous medical history”

Past medical history


Antenatal period – illnesses or complications during gestation – e.g. rubella

Birth – delivery complications / prematurity / birth weight

Neonatal period – illness /admission to a special care baby unit (SCBU)?

Medical conditions

Previous hospitalisation – when and why?

Previous surgery

Accidents and injuries – remain vigilant for signs of non-accidental injury

152
Drug history
Regular medication – e.g. inhalers for asthma

Over the counter medication

ALLERGIES

Developmental history
Current weight and height – weight is required to calculate drug doses

Developmental milestones (are they on track for their given age?):

 e.g. sitting up, crawling, walking, talking, toilet training, reading

Immunisations
Is the child up to date with their immunisations?

Dietary history
Type of food? – formula/breast milk/solids

Intake – e.g. how many ounces of milk?

Frequency of feeding – reduced or increased?

Special dietary requirements? – cow’s milk intolerance/coeliac disease

153
Family history
Family history of disease – e.g. coeliac

Genetic conditions – e.g. cystic fibrosis

Family tree – useful to draw out if considering genetic disease

Social history
Living situation – accommodation / main carer / who lives with child?

Second-hand smoke exposure – risk factor for otitis media/asthma

Parent’s occupation

Pets – important when considering allergies/asthma triggers

Schooling – stage of learning / any issues?

Foreign travel – may be important when considering certain diagnoses e.g. TB

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.

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

154
Respiratory – Dyspnoea / Cough / Sputum / Wheeze / Haemoptysis / Chest pain

GI – Appetite / Nausea / Vomiting / Indigestion / Dysphagia / Weight loss / Abdominal pain / Bowel habit

Urinary – Volume of urine passed / Frequency / Dysuria / Urgency / Incontinence

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

Musculoskeletal – Bone and joint pain / Muscular pain

Dermatology – Rashes / Skin breaks / Ulcers / Skin lesions

ALCOHOL HISTORY TAKING


Posted by Dr Anna Birtles | History taking

155
Table of Contents
We’d really appreciate if you could leave us a rating
Taking an alcohol history can be a bit daunting at first – especially as you’re asking questions which may
upset or anger a patient. However, it is important that history taking is as thorough as possible, so below is a
template to elicit this information (with some stock phrases for difficult questions, which you might find
handy!)

Personally, I find that signposting throughout allows the patient to prepare for more difficult questions, and
allows you to organise yourself – these are in quotation marks between the sections.

If anyone has any other ways of asking questions that they like, feel free to leave them in the comments. Check
out the alcohol history taking mark scheme here.

SCREENING
ALCOHOL INTAKE
IMPACT OF ALCOHOL
PAST MEDICAL HISTORY
PSYCHOLOGICAL ASSESSMENT
CLOSING THE CONSULTATION
INTERACTIVE MARK SCHEME
MARK SCHEME (PDF)

156
Opening the consultation
Introduce yourself – name/role

Ask the patient to confirm who they are – name / DOB

Explain the purpose of the consultation and gain consent

“I’ve been asked to come and speak to you today regarding your alcohol intake. Is that okay with you?”

“I appreciate that some of these questions may be difficult, but it is important that you are honest. If you would
like to stop at any time, let me know.”

Find out the reason for their presentation:

“What is it that has brought you in to see us today?”

Screening
It’s useful to assess severity at this point and to get an overall idea of the person’s drinking habits.

The CAGE questionnaire comes in useful here! A score over 2 suggests problematic drinking.

“I’m going to ask some general questions about your alcohol use and how it affects you.”

C – Have you ever felt that you should cut down on your drinking?

A – Do you get annoyed if people comment on the amount which you drink?

G – Do you ever feel guilty about the amount you drink?

E – Have you ever had an eye-opener? (A drink first thing on the morning to stave off a hangover – ‘”to stop
the shakes ” / “settle the nerves” / “hair of the dog”)

“Do you feel that you have a problem with alcohol?” (if so, enquire when this started/why)

157
Details of alcohol intake
When did they have their first drink? – good/bad experience?

When did they notice their alcohol intake increase?

 “Did your drinking gradually increase, or was the increase sudden?”


 “Is there anything in your life you feel caused your intake to increase?”(think adverse life events)

Current drinking pattern:

 Every day? / Weekends?

 Time of day – mornings / evenings / all day

Quantify and clarify intake:

 “How much do you drink, in an average day?”


 “What do you drink? When?”
 “How much do you drink at that time?”
 “Where do you tend to drink?”
 “Who do you drink with?”
 “What do you drink in a week?”
 “Is there anything that makes you drink more/less in a day?”
 “How much do you spend on alcohol?”
It may be useful to write down alcohol intake on a piece of paper (Monday – Sunday with approximate timings
and drinks had). This ensures a history which is as comprehensive as possible and accounts for varied intake
across the week.

Assess the impact of alcohol


Dependence
Biological signs of dependence present?

 “If you stop drinking, do you…get the shakes/sweat a lot/feel sick/notice any physical changes?”
 “Do you have to drink more than you used to, to get the same effects?” (tolerance)

158
Psychological signs of withdrawal present?

 “Do you feel a compulsion/need to drink?”


 “How important is drinking to you?”
 “If you stop drinking, do you notice that you…feel down/angry/anxious?”

Effects on daily living


Diet – adequate intake? / type of food (balanced?) / eating pattern

Occupation – is the patient working? / what is their job? / is it impacted by drinking?

Relationships – has alcohol impacted friendships/relationships?

Alcohol-related crime? – particularly aggression, drunk and disorderly, drink driving

 “Have you been in contact with the police as a result of alcohol-related incidents?”
Living situation? – where do they live / who do they live with?

Previous attempts at abstinence:

 “Have you ever tried to stop drinking before? Why?“


 “Why do you think it was unsuccessful?“
If not already revealed, assess desire to stop drinking

Here, it would be polite to thank the patient for divulging the information…

“Thank you for sharing that information with me. Now, we’ll move on from talking about alcohol to ask some
questions about your health at the moment.”

Past medical history


General screen
General medical history / previous surgery

“Is there anything you see your doctor for regularly?”

“Have you ever had any surgery in the past?”

159
Alcohol-use specific
Liver disease / peptic ulcers /pancreatitis /ischaemic heart disease

 “Have you ever had to go to hospital for drink-related illnesses/injuries?”

Drug history
Prescribed medication – “Are you prescribed any medication / Do you take it?”

Over the counter medication – Aspirin / St John’s Wort / other herbal remedies

Recreational drug use – “Do you take any other recreational drugs?”

Allergies
Ensure to document clearly any allergies stated.

Clarify what the allergic reaction was – e.g. lip swelling vs “a bit of a rash”

Family history
Focus particularly on history of alcohol/drug dependence

History of any mental illness

Psychological assessment
“Lastly, I’m just going to ask some questions about your mood. These may seem a little strange, but we ask
them to everyone who comes in with issues like this.”

Assess risk
Assess risk to self:

 “How has your mood been?”


 “How is your appetite?”
 “What is your sleeping pattern like?”
 “Are there things you enjoy in life? What?”
 “How is your concentration?”
160
 “Have you had any thoughts of hurting yourself?”
 “Have you ever thought of ending it all?” (If so, any plans)

Assess risk to others:

 “Do you ever have thoughts of harming others?”


 Note who is at home – if any dependents etc

DEPRESSION HISTORY TAKING


Posted by Dr Anna Birtles | History taking

161
Table of Contents
We’d really appreciate if you could leave us a rating
Taking a depression history is an important skill often assessed in OSCEs. It’s a key skill that you’ll require
whichever speciality you’re heading towards. The guide below provides a structured framework to ensure
that all of the key points are covered in addition to some stock phrases that may come in handy. Check out
the depression history taking mark scheme here.

OPENING THE CONSULTATION


SCREENING FOR CORE SYMPTOMS
SYMPTOMS OF DEPRESSION
PAST PSYCHIATRIC HX
PAST MEDICAL HX
SOCIAL HISTORY
INTERACTIVE MARK SCHEME
MARK SCHEME (PDF)

A few general tips for these type of situations:

162
 Use the patient’s own language when describing their feelings, and use this to get them to expand on their
presenting symptoms. Repeating parts of phrases can help develop the consultation and show the patient
you are listening and trying to understand.

 Be careful with your “active listening” fillers – nodding and making affirmative noises to show engagement
may be more appropriate than saying “Okay…”, you may accidentally re-affirm some of the patient’s
negative beliefs about themselves or their situation.

 Don’t be afraid to (sensitively) ask about suicide risk. Screening for risk and asking about suicide does not
increase the likelihood of a patient attempting it!

 Signpost and summarise as you go.

Definition of depression
ICD-10 criteria
Depression is;

 persistent sadness or low mood; and/or

 loss of interests or pleasure

 fatigue or low energy

At least one of these, most days, most of the time for at least 2 weeks.

Additional symptoms to ask about include:

 Sleep

 Appetite

 Concentration

 Low confidence

 Suicidality

 Agitation

 Slowing of movements

 Guilt

163
These will help you to determine the severity of depression, as shown in the table below.

Not depressed <4 symptoms

Mild depression 4 symptoms

Moderate depression 5-6 symptoms

Severe depression 7 symptoms +/- psychotic symptoms


Symptoms should be present for a month or more and every symptom should be present for most of every day.

Opening the consultation


Introduce yourself – name/role

Confirm patient details – name/DOB

Confirm reason for presentation:

“What’s brought you in to see us today?”

Open questions can help the patient to explain how they are feeling, without placing words into their mouth or
assuming a specific reason for presentation.

Developing a rapport
Enquiring about mood and general feelings before jumping into a history may help the patient feel
more at ease:

“How are you today?”

“How have you been feeling recently?”

164
Screening for core symptoms
Screen for core symptoms of depression :

 persistent sadness or low mood; and/or


 loss of interests or pleasure (anhedonia)
 fatigue or low energy

“In the past month have you…”

 Felt down, depressed or hopeless?


 Found that you no longer enjoy, or find little pleasure in life?
 Been feeling overly tired?

Assessing symptoms of depression


Screen for the presence, and assess the extent of any biological symptoms.

Biological symptoms
Sleep cycle

“How has your sleep pattern been recently?”

“Have you had any difficulties in getting to sleep?”

“Do you find you wake up early, and find it difficult to get back to sleep?”

Mood

“Are there any particular times of day that you notice your mood is worse?”

“Does your mood vary throughout the day?”

“Do you find that your mood gradually worsens throughout a day?”

Appetite
165
“Have you noticed a change in your appetite?”

“What is your diet like at the moment?”

“What are you eating in a typical day?”

Libido

“Have you noticed a change in your libido?”

“Since you have been feeling this way, have you noticed a difference in your sex drive?”

Cognitive symptoms
Screen for, and assess the extent of any cognitive symptoms of depression.

Concentration

“How do you feel your ability to concentrate has been?”

“Can you follow TV programmes/ read the newspaper/*insert hobby here* without getting distracted?”

Perception of current/future situation

“How do you feel about your current situation?”

“How do you feel about the future?”

Perception of self

“How do you feel about yourself?”

“Do you often criticise yourself?”

“Do you blame yourself when things go wrong?

166
Ruling out differential psychiatric diagnoses
Identify any previous episodes of mania (rule out bipolar affective disorder diagnosis at this time)

 “Have you ever experienced periods of feeling particularly high/energetic/euphoric?”

Elicit any evidence of psychosis

When asking these questions, you may find it useful to use a lead-in. This allows you to signpost,
maintain the patient’s trust, and normalise any feelings they may have, enabling an open conversation.

“People who feel the way that you have been describing can experience some seemingly bizarre events
and feelings…”

 “Have you ever heard voices speaking when there seems to be no-one around?”
 “Do you ever feel that people are discussing you negatively?” (If so, get context!)
 “Do you fear that people may be ‘out to get you’?”
 “Have you ever felt that something or someone is able to put thoughts into your head?”
 “Have you ever felt that something or someone can remove thoughts from your brain?”
 “Have you noticed any sensations that seem odd or inexplicable?”

Assess risk
Assess suicide risk, and risk of harm to self.

Again, this is something that you may feel more comfortable approaching with a lead-in!

 “When people feel down and depressed, they can feel that life is no longer worth living. Have you ever felt like
this?”
 “Have you had any thoughts of taking your life?” (if so – how often, when) / “Have you thought of how you
would do something like this?” /“Have you made any plans?” / “Have you ever tried to take your own life?”
 “Have you tried to hurt yourself in any way?” If so, how – if not “Have you thought of hurting yourself?”
 “What things do you have that you feel stop you from harming/killing yourself?”
 “Are you managing to eat and drink as you usually would?”
 “Has your alcohol intake changed?”, “Have you been relying on anything to help you feel better? ” (Drugs,
alcohol, food, etc.)

167
 “Have you felt able to see your friends/socialise?”

Past psychiatric history


Previous episodes of depression or dysthymia:

 “Have you ever felt like this before?”


 “Have you ever had any other periods of feeling particularly low?”

Previous psychiatric history:

 “In the past, have you had any problems with your mental health?”

 “Have you had any counselling for any issues before?”

 “Have you ever been admitted to hospital because of your mental health?” (If so, obtain details – time, method
of admission, result.)

Past medical history


Any chronic illnesses, or biological basis for mood disturbance (chronic illness is a major risk factor for
depression).

 “Do you have any medical conditions?”


 “Is there anything you see the GP for?”
 “Have you ever been in a hospital for any reason?”
 “Is there anything you take medication for?”

Drug history
Note current medications and record allergy status
168
 “Are you prescribed any medication at the moment?” if so, check compliance
 “Do you take any other medications?”
 “Do you buy any medications over the counter?”
 “Do you take any herbal remedies?”
 “Has the dose changed of any of your medications recently?”
 “Is there anything you are allergic to?” if so – note reaction

Family history
Enquire about any physical or psychological illnesses in the family.

A genogram may be useful – to account for family relationships and history of psychiatric illness in the
family.

Social history
Determine the social circumstances of the patient:

 “Who lives with you at the moment?”


 “Where are you living at the moment?”
 “Do you have any financial or housing concerns?”

Assess the impact of the depressive symptoms on the individual’s relationships and work:

 “Has your mood affected your friendships?”


 “Are you able to socialise regularly with others?”
 “Are you in a relationship at the moment? Has this been affected?”
 “Have you told any friends/family/anyone how you are feeling?”
 “Has your mood affected your ability to work?”
 “Are you able to concentrate on tasks at work?”
 “Has your mood caused you to take any time off work?”

Elicit patient’s drug, smoking and alcohol intake, if not already elucidated:
169
 “Do you smoke?”
 “Do you drink alcohol?”
 “Do you take any other drugs?”

Insight
Assess if the patient has insight into their problem:

 “Do you feel there is something wrong?”

ICE – Ideas, concerns and expectations:

 “What do you expect/what would you like from the consultation?”

170
HOW TO TAKE A MEDICATION HISTORY
Posted by Adam Rathbone | History taking, Information giving

Table of Contents
We’d really appreciate if you could leave us a rating
Many patients take multiple medications, prescribed by multiple professionals, in multiple settings.
Often information about medicines is poorly transferred, therefore a structured approach to the patient’s
medication history should be taken.

This guide can be used in two ways; to enhance any history that includes a drug history (including in an
OSCE) or specifically by professionals wanting to focus on collecting a detailed drug history, such as
pharmacists and pharmacy technicians or doctors and nurses during medication review consultations.

Check out the Medication History OSCE Mark Scheme here.

Opening the consultation


 Introduce yourself: name and role

 Confirm the patient’s details: name and DOB

 Explain the reason for the consultation

171
 Gain consent

 Ensure the patient is comfortable

 Start by asking if the patient has any concerns about their medication?

 If the patient does have concerns, try not to address them straight away, as without knowing the patient’s
full pharmaceutical history you can not really know how complicated their concern may be. If the patient
has a concern, say something like “we can come back to that once we know a little bit more about your
medication history.”

Example
“Hello, my name is Adam and I’m the pharmacist working on the ward today.”

“Can I confirm your name is [Mary Smith] and your date of birth is [12th July 1958]”

“I’d like to ask you some questions about your medication. Is that okay?”

“Before we start, do you have any concerns about your medication that you’d like to bring up?”

“We can come back to that issue once we know a little bit more about your medication history.”

Currently prescribed medication


This section forms the basis of the history. There are six key bits of information you need to obtain
about medication the patient is taking – the super six.

1. What is it? (drug name or characteristics)


This seems like a pretty obvious one but you’ll be surprised how often it gets missed. The pronunciation
of drug names varies greatly so you may need to think outside the box when the patient tells you they’re
taking a product that you’ve never heard of. Patients might also describe their medication based on
colour, size, the shape of the actual formulation or the container (e.g. “The little red ones that come in
the big green box”).

2. What is it for? (indication)


172
Many drugs have multiple indications and the most common indication may not be the reason the
patient is taking the medication. Indications also change with time as products come in and out of
fashion. For example, at one time, pregabalin was prescribed only to treat epilepsy, whereas now it is
prescribed for neuropathic pain and generalised anxiety disorder. Medications can provide important
collateral information for the medical history. The patient may not mention that they have pain or anxiety
in their medical history but if they’re taking medication for it, then they probably have a diagnosis that
may have been missed, so it is important not to make assumptions about what the drug is being used
for.

3. How much (or how many)?


When asking patients for information about their medication, it is important to remember they may not
think about doses in terms of milligrams or micrograms but rather one or two tablets, spoonfuls,
capsules, puffs etc. It can be worth asking how ‘strong’ the medication is as sometimes patients will
describe the dose of their medications this way.

4. How often?
This question provides two useful bits of information. Firstly it provides you with information about the
full dosing regimen by providing the frequency (e.g. the patient takes one pink capsule three times a
day). It also provides some information about the patient’s adherence to their treatment. In response to
this question, the patient may say ‘now and again’ or ‘every day’ and this can help you identify if their
presenting complaint may be due to medication non-adherence, including over and under-use.

5. Since when?
Knowing how long the patient has been taking a medication is important, as this changes the likelihood
of risks such as Type A pharmacokinetic effects (e.g. diarrhoea, hypoglycaemia, hypokalaemia), Type B
pharmacodynamic effects (e.g. anaphylaxis, blood dyscrasias) or Type C statistical effects (e.g. typically
only seen at cohort level when patients have been using medication for a long period of time e.g. gastric
ulceration with NSAIDs).

6. How do you take it?


Medication can behave differently depending on how it is taken. For example, medication that is taken
with food is absorbed more slowly than medication taken on an empty stomach. Another example is a
medication that is taken with milk (or close to breakfast) can chelate and not be absorbed at all, so it is
important to find out how the patient takes the medication. This question should also help you identify if
the patient is using a multiple-compartment compliance aid (‘MCCA’, aka a dosette box, tray, NOMAD,
pill box) which, if not identified, can significantly delay discharge from hospital. This question will also
help you to clarify what formulation the medication is (e.g. liquid, capsules, inhaler or subcutaneously

173
injected etc). This is important to know as it may influence further investigations you may wish to do,
such as to explore the patient’s inhaler technique.

After gathering this information you should summarise your findings to the patient to double check you
have got the correct information.

You should ask the super six about each and every medication that is prescribed for the patient. You
may notice that some patients will start to readily volunteer the information as they predict which
question is coming next. Make sure to give the patient plenty of time to answer and try not to interrupt
them.

Example
“I’d like to start by finding out what medications you are prescribed by your GP or any specialists that
you see and dispensed by a pharmacy?”

1. What is it? What do you call the medication you take?

2. What is it for? Why do you take that one?

3. How much (or how many)? How much of that do you take?

4. How often? How often do you take that? Is that [x] times a day regularly or just now and then?

5. Since when? How long have you been taking that?

6. How do you take it? On a typical day, how would you take that one? With food, or on an empty
stomach?

“Okay, just to summarise, you take [pregabalin] for [anxiety], [one capsule] [three times a day]. You
have been on it for [6 years] and you take it [regularly, on an empty stomach]. Is that right?”

*Repeat for each prescribed medication*

“Okay, thank you.”


174
Non-prescribed medications
After asking about prescribed medications, it’s important to check that the patient doesn’t take anything
else that is not prescribed that they purchase over-the-counter or, increasingly, from the internet for
self-care.

This could include supplements, vitamins, and herbal or homoeopathic remedies.

This is an important part of the drug taking history, as many of these products will influence the
pharmacodynamic and pharmacokinetic properties of prescribed medication. For example, St John’s
Wort can increase the metabolism and therefore reduce the efficacy of oral contraceptives.

It is important to ask the patient where they source their non-prescribed medications. If the products are
purchased from a pharmacy, it is likely the product is high-quality and is what it says it is. However, if
purchased online or from overseas, then the patient may be using a poor quality product. If this is the
case, you should ask to see the product and ask the senior pharmacy team for support, particularly if
the pathology of the presenting complaint is unclear.

Example
“Do you take anything that you buy from a supermarket or over the internet?”

If yes, use the super six to find out more information about those products followed by:

“Where do you get that from?”

Extra medications
When asking about prescribed and non-prescribed medication, patients often forget to mention products
that they may not classify as medications, such as eye drops, inhalers, sprays, patches or creams.
However, many of these products contain pharmacologically active ingredients that can cause or
exacerbate medical conditions.

175
Example
“Do you take any eye drops, ear drops, inhalers, sprays, patches, injections, creams or ointments?”

When asking about extra medications, it can be helpful to point to your eyes, ears, mimic using an
inhaler or spray, applying a patch to the top of your arm, or applying a cream. This isn’t evidence-based
but it can trigger the patient’s memory (and can be entertaining to watch).

If the patient says they take any of those, use the super six to obtain a thorough history.

Social pharmacy history


A patient’s social history can provide useful information when reviewing their pharmaceutical care. For
example, smoking tobacco induces enzymes that speed up the metabolism of theophylline and changes
in vitamin K consumption can reduce the efficacy of warfarin. Asking about a patient’s social history also
facilitates asking questions about any recreational drug use such as cannabis or ecstasy.

Asking questions about the patient’s lifestyle will also provide collateral information about their treatment
adherence. For example, someone who leaves at 5 am for a 90-minute commute to work is unlikely to
want to take their Furosemide first thing in the morning. Additionally finding out if the patient has any
support at home to take their medications may influence future prescribing decisions.

This is also a good opportunity to ask about any side effects or allergiesthe patient may have to any
medication.

Example
“I’m going to ask you some questions about your lifestyle now, is that okay?”

“Talk me through a typical day, from when you wake up to when you go to bed and how your
medications fit into that?”

Listen carefully to the patient’s response. Use the questions below to help clarify any missing
information.

Occupational history
“Do you work?”

“What do you work as?”

176
Support at home
“Do you have any help with your medications at home?”

“Is this from carers or your family?”

Smoking history
“Do you smoke any tobacco?”

“How much?”

“How often?”

“Since when?”

Alcohol history
“Do you drink any alcohol?”

“What?”

“How much?”

“How often?”

Recreational drug use


“Do you use any recreational drugs, like cannabis?”

“What?”

“How much?”

“How often?”

Diet and exercise


“What do you usually eat?”

“Do you do any exercise?”

“What types of exercise do you do?”

“How often?”
177
Side effects
“Have you ever had any side effects to any medications?”

Allergies
“Do you have any allergies to medications?”

Providing information
Identifying the pharmaceutical care issue
At this stage of the consultation, you should revisit any concerns the patient may have had about their
current medication regime. It’s also important to give the patient the opportunity to raise any additional
concerns about their medication.

If you have identified your own concerns about the patient’s medication regimen, for example, if the
medication is not being used correctly, you should raise them for discussion with the patient in this part
of the consultation. The patient will be able to offer you their perspective and you can negotiate the best
way to address these concerns.

If a patient is unwilling to change the way they use a medication and you feel that they’re at high risk of
significant harm then you can say something like “I’m going to have to stop that medication because…”

Example
“You mentioned you were concerned about …. is there anything else you’re concerned about?”

“Something I’m concerned about in relation to your medication is that ….”

 “You mentioned that you take your ibuprofen without food?”

 “You mentioned that you miss your insulin now and again?”

 “You mentioned that you crush your modified-release carbamazepine?”

178
“I’m concerned about this because….”

 “When you take ibuprofen that way it can upset your tummy and cause ulcers.”

 “When you miss insulin it can cause problems for your diabetes.”

 “When you crush your carbamazepine it may not work as effectively as it should.”

“Would you be interested in changing the way you use that medication?”

Propose an acute plan of action


The action plan will depend greatly on the patient’s perspective. They may be unwilling to change too
many medications at once because it will disrupt their routine or they may be fearful that their condition
might get worse.

Pharmaceutical management plans may include any of the following points:

 No changes to the current regime

 Reduce/increase dose

 Withhold a medication temporarily

 Additional therapy to deal with a side effect (e.g. adding a laxative following opioid-induced constipation)

 Referral to a specialist pharmacist, medical consultant, GP or nurse if you have reached your level of
competence and require additional input

Plans should include short-term and long-term outcomes.

Short-term plan

 The goal?

 Who will do what?

179
 Over how long?

 Any monitoring required?

Long-term plan

 Who will do what?

 Over how long?

 Any monitoring required?

Example
“Okay, so in the short–term, we would like to reduce your dose of diazepam as you feel like it is making
you too drowsy.”

“Let’s change your dose from tomorrow so you take 5mg less.”

So for the next two weeks, you will only take one diazepam tablet each day.”

“I will give you a call in two weeks to see how you’re getting on. Is that okay?”

“In the long-term, I think the rest of your medication is okay.”

“We can ask the GP to review everything again in six months.”

“I don’t think we need any additional monitoring or tests done at this point for anything. Is that okay?”

Closing
When closing the consultation it’s a good idea to summarise as much as you can, including the
information on the currently prescribed medication, the non-prescribed and the extras to make sure
nothing has been missed. You should also summarise the short term and long term plan so the patient
understands it fully and give the patient a final opportunity to ask any questions about what has been
covered and anything that has not been covered.

180
Example
“Okay, so we’ve discussed your medication which included [two inhalers, your medication for anxiety,
pain, diabetes, epilepsy and headaches and the vitamins you buy over the counter]. The plan is to
reduce your diazepam by one tablet each day and I’m going to call you in two weeks to see how you
feel that is going and then review everything else again at your usual review appointment with the GP
surgery.”

“Do you have any questions about what we’ve covered in this consultation?”

“Do you have any questions about anything we haven’t covered that I may be able to help with?”

“If you think of anything afterwards, my name is Adam and you can get in touch with me by asking the
nurses to contact pharmacy/calling me on 1234 567 8912”

“Thank you”

After the consultation


The patient is the most valuable source of information in relation to their medication – they’re the ones
who ultimately take them. However, if possible, you should try and obtain a collateral history from
another source to confirm the patient’s doses.

Some sources you may want to consider using include:

 Summary Care Record

 Hospital records

 Patient’s copy of their repeat prescription

 The actual products (some patients bring their medication to consultations or hospitals in a Green Bag
which makes it much easier to check doses. Be wary that this medication is actually the patients and not
their partner’s or pet’s.)

 Care home medication administration record

 Community pharmacy

 Family members or carers

181
Following the consultation, you should try and record the information in the patient’s notes, including
what sources you used. It may be possible to add this to the patient’s current prescribed medication if
you’re using an electronic prescribing system or you may have to free-type or write out the information
directly into the patient’s paper notes. This can be time-consuming but try not to rush – many significant
patient safety incidents occur because medication-related information is transcribed incorrectly. Take
your time and double check that what you have documented is what you intended.

If you’re free typing/handwriting in paper notes, try and include the super six pieces of information for
each medication as a minimum as well as your short and long-term plan of action.

182
PYREXIA OF UNKNOWN ORIGIN HISTORY TAKING
Posted by Nasreen Bahemia | History taking

Table of Contents
We’d really appreciate if you could leave us a rating

Introduction
Pyrexia of unknown origin (PUO) is defined as fever of 38.3°C or greater for at least 3 weeks with no
identified cause after three days of hospital evaluation or three outpatient visits.¹
Additional categories of PUO have since been added, including nosocomial, neutropenic and HIV-associated
PUO. ²,³

The most common causes of PUO include the following: 4

 Bacterial infections (e.g. abscesses, endocarditis, tuberculosis, osteomyelitis)

 Viral infections (e.g. CMV, EBV, HIV)

 Autoimmune conditions (e.g. rheumatoid arthritis, mixed connective tissue disease, polymyalgia
rheumatica)

 Malignancy (e.g. Hodgkin’s/non-Hodgkin’s/leukaemias)

Check out the pyrexia of unknown origin history taking mark scheme here.

183
HPC
PAST MEDICAL HX
DRUG HX
FAMILY HX
SOCIAL HX
SYSTEMIC ENQUIRY
CLOSING THE CONSULTATION
MARK SCHEME (PDF)

Opening the consultation


Introduce yourself

Confirm patient details – name and age (age-appropriate malignancies can be screened for)

Explain the need to take a history

Gain consent

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 your fevers”

History of presenting complaint


184
Fever history
Onset – clarify when the patient first noticed their fevers

Duration – infectious causes become less likely with increasing duration of the fever

Severity – check if the patient has been recording their temperatures, and if so, ask about the readings

Progression:

 Is there a pattern to the fever?

 Is the frequency of fever changing?

Precipitating factors:

 Was there any obvious trigger that preceded the onset of fevers?

Relieving factors:

 Does anything help alleviate or minimise the fever? (e.g. paracetamol)

Associated features:

 Malaise

 Nausea/vomiting

 Night sweats

 Fatigue

 Rigors

 Weight loss

 Pain (clarify location)

 Swelling (abscess, lymphadenopathy)

 Skin changes (e.g. rash, itch)

185
Previous episodes:

 Have you ever experiences prolonged episodes of fever in the past?

Infectious disease
Recent infections:

 Type of infection

 Symptoms

 Check if all of the symptoms have fully resolved

 Ask what treatment the patient received and if they took it as prescribed (e.g. did they finish their course of
antibiotics?)

Local exposures:

 Sick contacts

 Food and water consumption

 Recent injuries (e.g. breaks in the skin)

 Contact with animals/pets/birds

 Sexual activity without contraception

 Tattoos/piercing

Travel history:

 Location (rural vs urban)

 Departure and return dates

 Chemoprophylaxis and compliance (e.g. Malarone for malaria)

 Vaccinations for trip

 Activity (e.g. water-based activity/animal contact)

 Accommodation (e.g. malaria bed nets provided)

186
 Insect bites

 Injuries (e.g. breaks in the skin)

 Food and water consumption

 Sick contacts

 Sexual activity

 Tattoos/piercing

Autoimmune disease
Symptoms associated with autoimmune disease include:

 Morning joint stiffness

 Joint swelling and pain

 Rashes

 Fatigue

 Dry eyes/mouth

 Red/painful eyes

 Dry cough

 Progressive shortness of breath

Malignancy
Symptoms associated with malignancy include:

 Night sweats

 Weight loss

 Fatigue

 Change in bowel habit (including blood in stool)

 Haemoptysis/haematuria

187
 Enlarging masses

 Bone pain

Past medical history


Immunisations – take a detailed history of immunisation status to ensure the patient is up to date will all
relevant vaccinations

Previous infectious diseases:

 Type of infections

 Symptoms

 Frequency of infections (if very frequent may suggest partial treatment or immune deficit)

 Ask specifically about common causes of PUO such as


HIV/Tuberculosis/Endocarditis/Abscesses/Osteomyelitis

Past medical history:

 Conditions that increase the risk of infectious disease (e.g. diabetes, Crohn’s disease, immune system
impairment)

 Organ transplant recipient – patient may be on immunosuppressive medication

Autoimmune conditions:

 Type of autoimmune condition (e.g. inflammatory bowel disease, rheumatoid arthritis, mixed connective
tissue disease, sarcoidosis)

 The current level of disease control (is the patient currently experiencing a flare?)

 Current treatments (often immunosuppressive in nature)

188
Malignancy:

 Type of malignancy

 Extent of malignancy (e.g. metastases)

 Treatments received (e.g. chemotherapy/radiotherapy)

 Date of the last cycle of chemotherapy (if recent the patient may be immunocompromised)

Past surgical history:

 Recent surgery

 Splenectomy

 Prosthetic joint replacements

 Prosthetic heart valves

 Metallic implants (e.g. spinal rods)

 Intravenous lines and drains

Family history
Malignancies (e.g. leukaemias, lymphoma) – clarify age of onset and environmental risk factors

Autoimmune conditions (e.g. inflammatory bowel disease, rheumatoid arthritis, mixed connective tissue
disease)

Infectious diseases (e.g. TB) – relevant if the patient has regular contact with the individual

Medications
Regular medications:

 Clarify the patient’s current regular medicines

189
 Ask about any recent changes, such as new medications or changes in dose

Antibiotics:

 Type of antibiotics

 Duration of treatment

Patients with autoimmune disease or organ transplant recipients are often taking
immunosuppressive medication, so you need to clarify what they are currently (or have recently)
taken:

 Long-term steroids

 Azothiaprine

 Methotrexate

 Tacrolimus

 Mycophenolate mofetil

 Monoclonal antibodies (e.g. rituximab)

Chemotherapy – if a patient is receiving chemotherapy there are several details you should clarify:

 Type of chemotherapy

 Number of cycles of chemotherapy

 When last chemotherapy was administered

Over-the-counter medications (e.g. paracetamol/herbal remedies)

ALLERGIES – always ask about drug allergies and clarify the details surrounding each

Social history
190
Occupational exposure (e.g. healthcare workers, exposure to animals)

Hobbies (exposure to water/animals/etc)

Home environment (consider exposure risks at home)

Smoking history (risk factor for malignancy and infection)

Alcohol history (risk factor for malignancy and infection)

Recreational drug use – clarify if drugs are administered intravenously as this is a significant risk factor
for infection (e.g. endocarditis)

Systems review
Localising symptoms associated with infection:

 Respiratory – cough, dyspnoea, haemoptysis (e.g. tuberculosis)


 Cardiovascular – chest pain (e.g. pericarditis)
 Gastrointestinal – abdominal pain/diarrhoea (e.g. inflammatory bowel disease)
 Hepatic – jaundice, nausea, right upper quadrant tenderness (e.g. hepatitis)
 Genitourinary – dysuria, frequency, haematuria (e.g. urinary tract infection)
 Central nervous system – headache, photophobia, seizures, confusion (e.g. cerebral abscess/encephalitis)

Localising symptoms associated with malignancy:

 Weight loss – a common symptom amongst most malignancies


 Haematological malignancies – bone pain, night sweats, weight loss
 Solid organ tumours – lungs (e.g. hoarse voice, finger clubbing, persistent cough, haemoptysis), colorectal
cancer (e.g. change in bowel habits, melaena, tenesmus), abdominal (masses, organomegaly, ascites)

Localising symptoms associated with autoimmune conditions:

 Rashes – lupus (butterfly rash), sarcoidosis (erythema nodosum), adult-onset Still’s disease (salmon-pink
coloured)
 Morning stiffness and joint swelling – rheumatoid arthritis, psoriatic arthritis

191
 Raynaud’s phenomenon can occur in many connective tissue diseases (e.g. rheumatoid arthritis, systemic
lupus erythematosus, systemic sclerosis)
 Headache, jaw claudication, scalp tenderness, vision loss – suggestive of giant cell arteritis which is
associated with polymyalgia rheumatica

192