Urological history taking is an important skill that is often assessed in the OSCE setting. It’s important to have a systematic approach to ensure you don’t miss any key information. The guide below provides a framework to take a thorough urological history. Check out the urological history taking mark scheme here.
Opening the consultation
Introduce yourself – name / role
Confirm patient details – name / DOB
Explain the need to take a history
Gain consent
Ensure the patient is comfortable
Presenting complaint
It’s important to use open questioning to elicit the patient’s presenting complaint
“So what’s brought you in today?” or “Tell me about your symptoms”
Allow the patient time to answer, trying not to interrupt or direct the conversation.
Facilitate the patient to expand on their presenting complaint if required.
“Ok, so tell me more about that” “Can you explain what that pain was like?”
History of presenting complaint
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 – anything make the pain worse or better?
- Severity – on a scale of 0-10 how severe is the pain?
Key urological symptoms:
- Dysuria
- Frequency
- Urgency
- Nocturia
- Haematuria
- Hesitancy and terminal dribbling
- Poor urinary stream
- Incontinence
- Fever / rigors – suggestive of infection / urosepsis
- Nausea / vomiting – often associated with pyelonephritis
If any of the above symptoms are present, gain further details
Onset – When did the symptom start? / Was the onset acute or gradual?
Duration – Minutes / hours / days / weeks / months / years
Severity – i.e. If the symptom was frequency – how many times a day?
Course – Is the symptom worsening, improving, or continuing to fluctuate?
Intermittent or continuous? – Is the symptom always present or does it come and go?
Precipitating factors – Are there any obvious triggers for the symptom?
Relieving factors – Does anything appear to improve the symptoms?
Previous episodes – Has the patient experienced this symptoms previously?
Ideas, Concerns and Expectations
Ideas – what are the patient’s thoughts regarding their symptoms?
Concerns – explore any worries the patient may have regarding their symptoms
Expectations – gain an understanding of what the patient is hoping to achieve from the consultation
Summarising
Summarise what the patient has told you about their presenting complaint.
This allows you to check your understanding regarding everything the patient has told you.
It also allows the patient to correct any inaccurate information and expand further on certain aspects.
Once you have summarised, ask the patient if there’s anything else that you’ve overlooked.
Continue to periodically summarise as you move through the rest of the history.
Signposting
Signposting involves explaining to the patient:
- What you have covered – “Ok, so we’ve talked about your symptoms and your concerns regarding them”
- What you plan to cover next – “Now I’d like to discuss your past medical history and your medications”
Past medical history
Urological diseases:
- Recurrent urinary tract infections (UTIs)
- Incontinence – stress incontinence / functional incontinence
- Prostate issues – benign prostatic hypertrophy / prostate cancer
- Renal – renal stones / pyelonephritis / chronic renal failure
Other medical conditions – e.g. diabetes predisposes to UTIs
Surgical history – cystoscopy / bladder surgery / renal surgery
Acute hospital admissions? – when and why?
Drug history
Relevant prescribed medication:
- Diuretics – may contribute to nocturia / incontinence
- Alpha blockers – commonly used in prostatic enlargement
- Nephrotoxic agents – e.g. ACE inhibitor – consider suspension
- Antibiotics – those with recurrent UTIs take prophylactic antibiotics
Other regular medications
Over the counter drugs
Herbal remedies
ALLERGIES – ensure to document these clearly
Family history
Urological disease – increased risk of renal stones if parents previously affected
Are parents still in good health? – if deceased sensitively determine age and cause of death
Social history
Smoking – How many cigarettes a day? How many years have they smoked for?
Alcohol – How many units a week? – type / volume / strength of alcohol
Recreational drug use
Living situation:
- House/bungalow? – adaptations / stairs
- Who lives with the patient? – is the patient supported at home?
- Any carer input? – what level of care do they receive?
Activities of daily living:
- Is the patient independent and able to fully care for themselves?
- Can they manage self hygiene / housework / food shopping?
Occupation – increased risk of bladder cancer in those working in specific industries – industrial dyes / textiles / rubber / plastics / leather tanning
Systemic enquiry
Systemic enquiry involves performing a brief screen for symptoms in other body systems.
This may pick up on symptoms the patient failed to mention in the presenting complaint.
Some of these symptoms may be relevant to the diagnosis (e.g. reduced urine output in dehydration).
Choosing which symptoms to ask about depends on the presenting complaint and your level of experience.
Cardiovascular – Chest pain / Palpitations / Dyspnoea / Syncope / Orthopnoea / Peripheral oedema
Respiratory – Dyspnoea / Cough / Sputum / Wheeze / Haemoptysis / Chest pain
GI – Appetite / Nausea / Vomiting / Indigestion / Dysphagia / Weight loss / Abdominal pain / Bowel habit
CNS – Vision / Headache / Motor or sensory disturbance/ Loss of consciousness / Confusion
Musculoskeletal – Bone and joint pain / Muscular pain
Dermatology – Rashes / Skin breaks / Ulcers / Lesions
Closing the consultation
Thank patient
Summarise history