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Taking a urological history is an important skill that is often assessed in OSCEs. This guide provides a structured approach to taking a urological history in an OSCE setting.
Opening the consultation
Wash your hands and don PPE if appropriate.
Introduce yourself to the patient including your name and role.
Confirm the patient’s name and date of birth.
Explain that you’d like to take a history from the patient.
Gain consent to proceed with history taking.
General communication skills
It is important you do not forget the general communication skills which are relevant to all patient encounters. Demonstrating these skills will ensure your consultation remains patient-centred and not checklist-like (just because you’re running through a checklist in your head doesn’t mean this has to be obvious to the patient).
Some general communication skills which apply to all patient consultations include:
- Demonstrating empathy in response to patient cues: both verbal and non-verbal.
- Active listening: through body language and your verbal responses to what the patient has said.
- An appropriate level of eye contact throughout the consultation.
- Open, relaxed, yet professional body language (e.g. uncrossed legs and arms, leaning slightly forward in the chair).
- Making sure not to interrupt the patient throughout the consultation.
- Establishing rapport (e.g. asking the patient how they are and offering them a seat).
- Signposting: this involves explaining to the patient what you have discussed so far and what you plan to discuss next.
- Summarising at regular intervals.
Presenting complaint
Use open questioning to explore the patient’s presenting complaint:
- “What’s brought you in to see me today?”
- “Tell me about the issues you’ve been experiencing.”
Provide the patient with enough time to answer and avoid interrupting them.
Facilitate the patient to expand on their presenting complaint if required:
- “Ok, can you tell me more about that?”
- “Can you explain what that pain was like?”
Open vs closed questions
History taking typically involves a combination of open and closed questions. Open questions are effective at the start of consultations, allowing the patient to tell you what has happened in their own words. Closed questions can allow you to explore the symptoms mentioned by the patient in more detail to gain a better understanding of their presentation. Closed questions can also be used to identify relevant risk factors and narrow the differential diagnosis.
History of presenting complaint
Patients with urological pathology can present with a wide variety of symptoms which we’ve summarised below.
Key urological symptoms
Symptoms that are typically associated with urological disease include:
- Dysuria: typically associated with urinary tract infection (UTI), including sexually transmitted infections (e.g. chlamydia, gonorrhoea).
- Urinary frequency: commonly associated with UTIs.
- Urinary urgency: may be associated with UTIs or detrusor instability.
- Nocturia: associated with UTIs and prostate enlargement (e.g. benign prostatic hyperplasia).
- Haematuria: associated with UTIs, trauma (e.g. catheter insertion) and renal tract cancers (e.g. bladder cancer, renal cancer).
- Urinary hesitancy, terminal dribbling and poor urinary stream: associated with enlargement of the prostate (e.g. prostate cancer, benign prostatic hyperplasia).
- Urinary incontinence: associated with a wide range of pathology including UTIs, detrusor instability and spinal cord compression (e.g. cauda equina syndrome).
- Fevers and rigors: typically associated with pyelonephritis.
- Nausea and vomiting: typically associated with pyelonephritis.
- Weight loss: associated with malignancy and uraemia.
- Uraemic symptoms: nausea, vomiting, fatigue, anorexia, weight loss, muscle cramps, pruritis and confusion.
SOCRATES
The SOCRATES acronym is a useful tool for exploring each of the patient’s presenting symptoms in more detail. It is most commonly used to explore pain, but it can be applied to other symptoms, although some of the elements of SOCRATES may not be relevant to all symptoms.
Site
Ask about the location of the symptom:
- “Where is the pain?”
- “Can you point to where you experience the pain?”
Onset
Clarify how and when the symptom developed:
- “Did the pain come on suddenly or gradually?”
- “When did the pain first start?”
- “How long have you been experiencing the pain?”
Character
Ask about the specific characteristics of the symptom:
- “How would you describe the pain?” (e.g. dull ache, throbbing, sharp)
- “Is the pain constant or does it come and go?”
Radiation
Ask if the symptom moves anywhere else:
- “Does the pain spread elsewhere?”
Associated symptoms
Ask if there are other symptoms which are associated with the primary symptom:
- “Are there any other symptoms that seem associated with the pain?”
Time course
Clarify how the symptom has changed over time:
- “How has the pain changed over time?”
Exacerbating or relieving factors
Ask if anything makes the symptom worse or better:
- “Does anything make the pain worse?”
- “Does anything make the pain better?”
Severity
Assess the severity of the symptom by asking the patient to grade it on a scale of 0-10:
- “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?”
Ideas, concerns and expectations
A key component of history taking involves exploring a patient’s ideas, concerns and expectations (often referred to as ICE) to gain insight into how a patient currently perceives their situation, what they are worried about and what they expect from the consultation.
The exploration of ideas, concerns and expectations should be fluid throughout the consultation in response to patient cues. This will help ensure your consultation is more natural, patient-centred and not overly formulaic.
It can be challenging to use the ICE structure in a way that sounds natural in your consultation, but we have provided several examples for each of the three areas below.
Ideas
Explore the patient’s ideas about the current issue:
- “What do you think the problem is?”
- “What are your thoughts about what is happening?”
- “It’s clear that you’ve given this a lot of thought and it would be helpful to hear what you think might be going on.”
Concerns
Explore the patient’s current concerns:
- “Is there anything, in particular, that’s worrying you?”
- “What’s your number one concern regarding this problem at the moment?”
- “What’s the worst thing you were thinking it might be?”
Expectations
Ask what the patient hopes to gain from the consultation:
- “What were you hoping I’d be able to do for you today?”
- “What would ideally need to happen for you to feel today’s consultation was a success?”
- “What do you think might be the best plan of action?”
Summarising
Summarise what the patient has told you about their presenting complaint. This allows you to check your understanding of the patient’s history and provides an opportunity for the patient to correct any inaccurate information.
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, in a history taking context, involves explicitly stating what you have discussed so far and what you plan to discuss next. Signposting can be a useful tool when transitioning between different parts of the patient’s history and it provides the patient with time to prepare for what is coming next.
Signposting examples
Explain what you have covered so far: “Ok, so we’ve talked about your symptoms, your concerns and what you’re hoping we achieve today.”
What you plan to cover next: “Next I’d like to discuss your past medical history and then explore what medications you currently take.”
Systemic enquiry
A systemic enquiry involves performing a brief screen for symptoms in other body systems which may or may not be relevant to the primary presenting complaint. A systemic enquiry may also identify symptoms that the patient has forgotten to mention in the presenting complaint.
Deciding on which symptoms to ask about depends on the presenting complaint and your level of experience.
Some examples of symptoms you could screen for in each system include:
- Systemic: fevers (e.g. UTI), weight change (e.g. malignancy)
- Cardiovascular: palpitations (e.g. electrolyte derangement), chest pain (e.g. uraemic pericarditis)
- Respiratory: dyspnoea (e.g. pulmonary oedema secondary to renal failure)
- Gastrointestinal: abdominal pain (e.g. peritoneal dialysis associated infection)
- Neurological: confusion (e.g. uraemic encephalopathy)
- Musculoskeletal: muscle wasting (e.g. end-stage renal failure)
- Dermatological: uraemic frost (e.g. end-stage renal failure)
Past medical history
Ask if the patient has any medical conditions:
- “Do you have any medical conditions?”
- “Are you currently seeing a doctor or specialist regularly?”
If the patient does have a medical condition, you should gather more details to assess how well controlled the disease is and what treatment(s) the patient is receiving. It is also important to ask about any complications associated with the condition including hospital admissions.
Ask if the patient has previously undergone any surgery or procedures (e.g. transurethral resection of the prostate – TURP):
- “Have you ever previously undergone any operations or procedures?”
- “When was the operation/procedure and why was it performed?”
Allergies
Ask if the patient has any allergies and if so, clarify what kind of reaction they had to the substance (e.g. mild rash vs anaphylaxis).
Examples of relevant medical conditions
Medical conditions relevant to urological disease include:
- Recurrent UTIs
- Urinary incontinence
- Prostate disease (e.g. benign prostatic hyperplasia, prostate cancer)
- Renal disease (e.g. renal stones, pyelonephritis, chronic kidney disease)
- Diabetes
- Bleeding disorders (e.g. haemophilia)
Drug history
Ask if the patient is currently taking any prescribed medications or over-the-counter remedies:
- “Are you currently taking any prescribed medications or over-the-counter treatments?”
If the patient is taking prescribed or over the counter medications, document the medication name, dose, frequency, form and route.
Ask the patient if they’re currently experiencing any side effects from their medication:
- “Have you noticed any side effects from the medication you currently take?”
Medication examples
Medications relevant to patients with urological issues include:
- Diuretics (e.g. furosemide): a common cause of nocturia and can cause acute kidney injury.
- Alpha-blockers: commonly used to treat prostatic enlargement
- Nephrotoxic medications (e.g. ACE inhibitors, NSAIDs): may cause acute or chronic kidney injury.
- Antibiotics: commonly required for recurrent UTIs and may be prescribed as prophylaxis.
Family history
Ask the patient if there is any family history of urological disease:
- “Have any of your first-degree relatives been diagnosed with kidney, bladder or prostate problems?”
Social history
Explore the patient’s social history to both understand their social context and identify potential urological risk factors.
General social context
Explore the patient’s general social context including:
- the type of accommodation they currently reside in (e.g. house, bungalow) and if there are any adaptations to assist them (e.g. stairlift)
- who else the patient lives with and their personal support network
- what tasks they are able to carry out independently and what they require assistance with (e.g. self-hygiene, housework, food shopping)
- if they have any carer input (e.g. twice daily carer visits)
Smoking
Record the patient’s smoking history, including the type and amount of tobacco used.
Calculate the number of ‘pack-years‘ the patient has smoked for to determine their risk profile:
- pack-years = [number of years smoked] x [average number of packs smoked per day]
- one pack is equal to 20 cigarettes
Smoking is a significant risk factor for malignancy of the renal tract.
Alcohol
Record the frequency, type and volume of alcohol consumed on a weekly basis.
Alcohol is a significant risk factor for malignancy.
Recreational drug use
Ask the patient if they use recreational drugs and if so determine the type of drugs used and their frequency of use.
Diet and fluids
Ask if the patient what their diet looks like on an average day, including fluid intake.
Patients who are chronically dehydrated are at increased risk of UTIs and renal impairment.
Occupation
Ask about the patient’s current occupation to clarify what their job role involves.
Working with industrial dyes, textiles, rubber, plastics and leather tanning are associated with an increased risk of bladder cancer.
Closing the consultation
Summarise the key points back to the patient.
Ask the patient if they have any questions or concerns that have not been addressed.
Thank the patient for their time.
Dispose of PPE appropriately and wash your hands.
