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things will help. We will send We'll we'll make a little page and medal, and we'll send you the instructions and details and then we'll upload it there. So you guys can see you later on. Mhm. Right. I think it would be good to start. Oh, Ronan can't hear needed, uh, you know that bar that you get when you start screen share ing? It was really annoying in the last one. Do you know how I can just, like, minimize it or get rid of it? You just move it. Is that okay? Fine. All right. I'll just have to work around it then. Right? Can everyone see the presentation? Yeah. Yeah. Cool. Also, any questions? Feel free to pop in the shop. We will answer it at the end or during break time. Um, yeah. So I'll get the My computer's a bit slow, but I know what the first slides are. So hell over when I'm Ronan. Nice to see. See all of you here. Uh, we have brisman as well. Um, so today we're going to be doing a presentation on, like, standard history taking. Um I know that you all kind of have done history taking over the last couple of years, I'm more just kind of going to go through, uh, my form of how I structured my presentations, Um, and really good ways to remember certain things. Uh, And what? To ask What not what isn't really as relevant to ask. Um, then after that, we're going to go through some specific history taking format, that being a pediatric history, Um, an obstetric history and a gynecology history. And then I was going to go through the most common kind of stations you can get. So the, uh, most likely related symptom that you'll get is a presentation which you'll be taking a history about. Okay, there we go. So that's just a breakdown. But I've kind of already gone through that basic history format and then format kind of the format to kind of follow for the more specialist histories. And what are the common presenting complaints? So, um, we all know how to kind of take a standard history, but this was my format of how I kind of approached stations. So the first kind of, uh, biggest one is Obviously you're presenting complaint. So how to ask around a particular symptoms. That symptom that's coming in. This could be chest pain, shortness of breath, and you have specific questions relating to that symptom. Um, but there's a really good pneumonic that I used to use, which I will go through later on that you can practically apply for any kind of symptom that comes through the door if you really get stuck, the most common one that we normally here is the Socrates one for pain. Um, this is quite similar, but it's almost like universal. So after you've done your presenting complaint, it's really important to do a system of you. This is kind of just checking a bodily system and how well it's functioning. What I used to do and I strongly recommend, is you do a General View review that's got all of your red flag symptoms kind of in one go. So weight loss, fevers and malaise. Those were the three big ones, really, and then dependent on what the present presenting complaint is, you will do another system of you. I normally like to do at least two. So a general system of you and then something else related, so an example would be you have a patient who's walked through the door and they've come in with some abdominal pain. The system of you is I would be thinking there, Let's say it's a male. I'm going to be asking a gastrointestinal system of you so any, uh, start from the top and work to the bottom. Any swallowing difficulties, any nausea and vomiting, then you get to your colon. Any bowel changes in your bowel habit? Any change in your stool? Once you've done that, you've done kind of your general system of you. The other one, I would think for, uh, an abdominal pain would be a urological system of you Ask a couple of questions like pain during, uh, going to the toilet wing. So this area and he has that's fine. And a system of you is not really there for you to kind of catch out. The actor, um, in them not telling you a particular symptom. It's more there to show the Examiner that you're ruling things out. So it's not for you to just go on this long spree of all these symptoms, it's more just to show the Examiner that you are just trying to rule out certain symptoms and certain diagnoses. So after you've done your system of you or system of use, more like then go onto your ice, you can do ice at the end. But I urge you all to do ice. Okay? So ideas concerns expectations. The most of the, uh, um consultations. There will be at least a couple where if you don't ask ice, then the actor most likely will not tell you a really important piece of information. It's probably the main reason that two of my stations I definitively past and didn't fail because they told me, uh, what I needed to hear during I'd during ice. And those were very common symptom, uh, stations that people actually failed on. I know that those were quite low score ing stations, and it's only because I just so happened to ask eyes. So definitely remember to do that. And then once you've done that, then you can go on to your past medical history, drug history and all those past medical history. You're going to say any medical conditions that that you see your GP for regularly or any conditions you diagnosed with. If it's an acute history. I would leave it at that. If you have seven minutes. I used to think of, um, just a couple just to show the Examiner that you're thinking about certain conditions that could be risk factors or even could be, um, related. And I used to use this MD heat. Um, it's a bit of a random and abbreviation, but it worked for me, and it just allowed me to think of Have they ever had an MRI in the past ever been diagnosed with diabetes, hypertension, epilepsy, asthma, or COPD? And TB, the diabetes and hypertension? The most important ones, really, it just because they basically predispose you to quite a lot of cardiovascular problems. Most systems. Um, so it is something that you can just throw in and ask, maybe. Have you ever been diagnosed with diabetes? Ever been diagnosed with hypertension? Fine. Then go on to your drug history. You want to ask about any over the counter medicines and any prescription meds and then never, ever forget. Do you have any allergies? And if they say that they have an allergy like a penicillin allergy, you always want to follow it up. With what? What reaction. Do you actually get with that allergy? It's very important. Then go on to your family history. So any conditions that run in the family and that's usually good enough, or any issues similar to what they present what you're presenting with in the family. And then that's kind of your family history done. And then your social history. I like to use this abbreviation lost. It works pretty much across the board, your Ehlers for your living situation, always for occupation. What they do or did s for smoking. And then I think, Well, if you weren't smoking, you're going to have to ask about all the other kind of bad things that you can consume. So your alcohol, your drug use and obviously being sensitive with those kind of questions Um, just, uh, while I'm thinking about it now, a piece of feedback I actually got on one of my stations in my whiskey was I said, I'm sorry, I have to ask this, but do you smoke? Do you drink alcohol? And the person actually brought me up, brought it up and said, Don't say I'm sorry to ask this because it assigns guilt to it. so saying something like, um, this is something that we have to ask everyone. Do you smoke? Do you drink alcohol? It's It's small changes to language that can, you know, make quite big differences to a consultation. And then finally, or t I think travel, You know, any infectious disease can cause practically any symptom that a human person can come in with. So it's, um, not a bad one to ask. And then just think about any other things that could possibly be related So common would be like chest pain. Um, you know, travels quite important. Have they been on a long haul flight or something? So, as I'm going back to that presenting complaint when I said, there's a really nice abbreviation you you can use, I used to use something called Sick Car. Okay, so really easy. And it practically can work for anything. So s for being start, I interim and see current. It's more to show the progression. So when did it first start? What was it like when it started? Has it changed since then? What's it like now and then You can also ask about the character of that symptom. So if it's shortness of breath, you might, um, you know, say, is it exercise induced or is it just kind of when you're outside? So, like, you know, does the cold weather bring it on or something? So you can ask kind of generalized questions about the character of that symptom. You're a associated symptoms, and that kind of comes into your system of you, but it's It kind of crosses over a bit. You find that a lot of history taking there's, uh, you can ask things at different points. Um, but it's a good way to kind of have some systematic approach to the presenting complaint. So then you've got your A and then our anything make it worse. Anything make it better. So we'll leave as an exacerbators. And from that you can basically ask about any symptom. Okay, Before I go on, I just want to ask, Did uh everyone happy with that? Any questions? We've got the asthma before I move on. No, that's funny. OK, so, uh, going on to appease History peas history. I've kind of highlighted the red as being what's slightly different from the presenting complaint structure? Uh, sorry. The generalized history structure that I went over before. So explore a symptom relevant system of use and ice and then following that, I like to use a a very good kind of systematic, uh, screening sort of tool, which is B F G d. So asking about their birth? Was there any issues during there during the mother's pregnancy? Any issues during their birth definitely consider whether it's relevant, dependent on the age of the child. Now, peas is anyone below the age of 18. But if you have a 17 year old that's presenting with chest pain, you're not really worried whether they had issues during the pregnancy or the birth. Really. So it's more context. But a classic peas presentation or where you want to ask about all of this is a two year old or one year old or a six month old coming in with something, then you're going to ask about all of this. So context is key. So asking about the birth, then going on to feeding, So think about it in two separate, uh, factors. What's going to go into into baby and what's or what's going into child and what's coming out. A child. So input. Are they feeding and eating well, The, uh, most common kind of, uh, issue that Children actually come in with in GP world is they've gone off their food and they're not. They're not eating as much, and it's quite telling if the baby has gone off their food. Um, that something's not quite right. So it's a very important point to us, and it's what is normal for them if they don't eat, if they only once a day and they're they're eating once a day. Still, it's not a change if they're eating, not at all during the day, that's very different. Um, then you want to look at their output. So is there any kind of change in their their stool? Um, quite often you can sort of talk about them as being two types of nappies and Children. At least I feel under the age of three, when they're still wearing nappies. You have have wet nappies, which is your P, and then you have your dirty nappies, which is your pin. So asking the mother how many wet nappies are they having? It might be four or five, and then how many dirty nappies are they having? And they might say, Oh, they have one dirty nappy a day. And when you're on the dirty nappies, you'll say, Have you noticed anything? Actually, in the dirty nappy that doesn't look quite right like some blood or some mucus or just something that that's a bit abnormal. If nothing, then that's fine. And you also want to ask about the amount. Obviously, is it more frequent? Is there a change in volume and so on? Then you can go on to your G, which is growth if they're under five. A really good question to ask, or something that you can even say during the consultation, which shows to the Examiner that you're considering. It is, Oh, do you have a red book and they'll they'll know what it is. I'll show you kind of late. I've got another slide. The Red Book is, um, this book, which mothers get after after a delivery for any child. Um, and it's basically a record of their weights over the course of a couple of years. It also records their vaccination history Mother's. In fact, I'll just go on, actually, um, so this is what a red book Looks like if you haven't seen one before, use it to record a child's weight. And this is over multiple months and you can. They'll be like graphs that you can see which actually allow you to see what's, um what's They're kind of, uh uh, state compared to the general population of Children of that age. So a very classic, uh, kind of question they might ask, actually, in the multiple choice exams is Oh, a child is kind of they're they've they've had a fall in their weight, but they're still in the same son tile Sen tile is kind of the broad, uh, weight distribution kind of for Children. Uh, so if your 10th percentile, it means you're in the 10% of what Children kind of scores away at that age and of that height. So it records your child's weight. You can also record the height and vaccinations, and then mum's can sometimes add, like extra details, like any illnesses that they've recently had. Are they reaching their developmental milestones and so on? So going back, if they're under five, you can ask the question, or are they growing all right at the moment and then you can also follow up with, uh, Do you have a red book for them? The most, The most Definitely. Say yes and you'll be like so on the red book. They, you know, uh, coming along nicely in the growth Is their growth chart looking okay? And most likely, it will be, yes, unless they've got some presentation related to growth problems. If they're over five years, then I would think, rather than asking about growth, you want to ask about pubertal development. So that's, uh, quite a good one to kind of show to the Examiner that you're thinking about some endocrine disorders that could be related to their presenting complaint. Um, for males, the first stage of pubertal development is the enlargement of testes. So you want to ask about kind of pubic hair and mails, testicle kind of growth, enlargement of the Penis growth actually height wise and changing their musculature females, the first changes breast development. And then, you know, at the end of all of that after they've had pubic hair development and growth as well will be the, uh, start of menstruation. So they're men are then after you've done their growth. You want to go on to development, so D And if they're under five, then there's four categories that you need to kind of tick off. That's your fine motor gross motor hearing a language and social. So I'll break each of these down. Fine. Motor is all you're fine movements. So quite good questions to ask is, Are they picking up things with their their fingers? Um, sometimes it will be. Can they play with blocks? And can they, like, build a tower of blocks? And if they're hitting certain age milestones, they'll be able to build more blocks? Um uh, they'll be able to make a bigger tower. In effect, there's there's a lot of different kind of milestones in each one, so I do recommend kind of having a look yourself, but these are kind of questions you can ask in each one. Gross motor, that's Are they walking? Are they calling? Uh, you know, if they're too, are they running? You know, you kind of get the picture. It's bigger kind of movements of the body in effect after that, hearing a language. So, you know, Are they turning to sounds? This is when they're very young. Are they Actually, at the age of 12 months, actually saying Mama and Dada, Uh, two years you might be asking where they actually formulating kind of sentences a bit. So putting a couple of words together and then social is how are they actually interacting with other people and then other Children? Um, you can ask a more extensive history about the development if the presenting complaint is relevant to it. So, for instance, if the presenting complaint is oh, they've been having a bit of difficulty reaching their walking milestone, then Absolutely, absolutely. You want to be doing a bit more kind of interrogation around each of these kind of, uh, subcategories. But if the presenting complaint is, they've got some abdominal pain, then I would more. I would kind of just ask the parent. Are they reaching their developmental milestones or another way to phrase it is the health visitor who kind of keeps a track of them their milestones. Are they happy with the progress they're making? And that that's another great way to tell If they're over five, then the best way to assess their development is schooling. So are they having any issues at school. Are they keeping up with their peers? If there's no issues, then the parent won't say. But if there is, the parent will volunteer something. And then after you've done all of that past medical drug history, family history, social history, it's a lot to pack all into seven minutes. But this is where I say it's important to, um, kind of compartmentalize what is more important to ask and what's less important to ask. So if you have a 16 year old presenting, I'm not going to really want to ask about the birth. I might ask about feeding as in. Are they eating normally? You know? And are they? You notice any change in their bowel habit that's feeding done growth. I might ask a bit more about their pubertal development and then development. You're gonna ask, Is everything okay at school? It's only going to take less than probably a minute to do that. And you've just screened most of that already. So it looks a lot, but actually, it's doable. Uh, come on. There we go. Okay. So, uh, going back to kind of the past Medical, drug history, social history, all that just important things, which are slightly different from the general format. So things to add drug history. You want to ask about immunizations, so we always add that into the mix. Social history. The lost format still works. It's just you're going to think about in a different way. So living situation, you're just going to ask, who do you, who? Who's at home with the child who's at home with, you know, Johnny the 10 year old or something? Occupation. A child's not going to be working, but they'll be in school or they might be in preschool or something. So you know, that's something that you can definitely ask about s smoking. You're not worried about whether the child smoking, but asking the parents whether they smoke is very important. Um, that can predispose the kids to a lot of different medical conditions, so that is important to us and asking, I always I think s for smoking and s for social services and Children. Social services are very important thing to be thinking about asking in any peas case, particularly if you've got some presenting complaint like bruise like a child coming with bruisers. But you're not gonna ask every single child to their parent has social service has been involved because it's it's quite sensitive question. But if the presenting complaint is something that's making you think about that, then absolutely, you need to ask her social service has ever been involved. So context, um, and then t asking maybe about travel or a more. A better question to ask is if a child a bit unwell, asking whether other Children and the family at home also unwell. Mm. So I'm not going to go through to some common kind of stations that come and come up for pediatrics. So a very common one is failure to thrive. I like to separate it into two kind of main categories. Is either going to be a GI problem where absorption is being impaired? So big ones are celiac disease, some kind of diet tolerance, pyloric, stenosis, IBD and so on. Um, all of these have their own unique histories, but celiac disease will be something like weight loss. They might also have some diarrhea, tummy pains and Children. Very commonly, if they've got some tummy pains, they'll do kind of like hunching in like almost a cradle form. If they've got, uh, reflux disease, then Children. Instead they arch their back like that. Almost imagine they're trying to, like, elongate the the esophagus. That's the best way I can remember it. So if they have tummy pain, they'll be hunched in. That's how the parent will explain it. If they've got reflux, they'll kind of arch like that. Yeah, non G eye is just all you have to kind of the most important one is neglect, really, and then chronic illness. So any kind of chronic illness in a child can cause failure to thrive. And that's where that system of you is really important. Just showing the Examiner that you're you're checking other things. So have they got any malaise? Have they got any fevers? The next most common presenting kind of complaint in the station is weight gain. There's only two kind of causes. Either you have an endocrine. I'm, um, problem. So hypothyroid Cushing's polycystic ovarian syndrome. PCOS will be more kind of your your, uh, girl who hasn't kind of had herpes hasn't had her, uh, men arc yet. She's also kind of developing masculine facial features. Uh, mail kind of like hair or something. Um And then you have your non endocrine, uh, kind of category. So that's even Vyron mental. So the either eat, they're eating too much or cause of edema. So any heart problems, any kidney problems, and then your genetic syndromes and the genetic syndrome will probably be an important one in your family history. But you ask, or does anyone else in the family have a similar kind of symptoms to this? And they'll be like, Oh, yeah, his dad, he had this and then you'll, you know, want to delve a bit deeper into that third presenting kind of complaint. Developmental delay. I kind of went into this already, but there's lots of different cause of developmental delays and Children. But really, the only thing that you need to differentiate is is it a generalized delay? So is it kind of taking a lot of boxes like fine motor, gross, motor, social? Or is it just a specific delay? So is it just one of them four? So I I did I, uh No, that's fine. I didn't cover up, you know, um, behavior problem is another one. I didn't really go into it before. But this is where it would be important kind of in in your history to take, um into account. Is there any problems at school? So your most common behavioral problems in Children is a D h D. So that I'll be hyperactive. Child has difficulty concentrating OCD, so they're very fixated on something. If you try and make them deviate away from particular task, they'll get quite annoyed or frustrated. Autism is they will have a lot of difficulty socially interacting with people presents quite similar to the OCD. Where, um, if you try and deviate them away from something they're fixated on, they'll also get quite annoyed and frustrated. And then your fourth one is something called conduct disorder. Um, not something that a lot like I I haven't really heard of it before, but it's basically when a child for no particular reason actually just wants to get into trouble. It's, uh, kind of trouble maker that knows they're doing something wrong. They like it, and even when you pull them up on it, they won't care. It's it's almost like a personality disorder in itself. Um, but if you are interested, do a bit of reading around that your fifth one, which is, uh, something which I definitely think they could actually give you on the day because it allows them to check a really specific red flag thing you should always check, which is the, um, you know, the possible abuse factor that's in play, which is childhood bruising. So childhood bruising. Either it's going to be some kind of clotting or coagulant disorder, or they've kind of just knocked themselves when they've fallen over. Or you're dealing with a possible abuse case. Um, and that's definitely something to mention in your, um, differential diagnoses on the day. So coagulation disorders you can have one secondary to militancy or other conditions, and then your most common kind of, uh, causes of kind of some bruising and a child, which is related to a clotting problem, would be your HSP her not Schonlein purpura, where you get the rash, which is on the buttocks and also the extensive services of the legs. And you can also get some kidney problems. They might also have some tummy upset with it as well. You then have I t p, which is idiopathic thrombocytopenic purpura. That's just when they basically got a low platelet count. Um, just correct me if I'm wrong, Wisma. It's while since I've looked into all these conditions, but they basically got a low platelet count. There's no really other factors besides their bruising a lot, and they have this low platelet count. Sometimes they may also have a viral illness a couple of weeks before and that sets it off. So asking whether they've been unwell over the last couple of weeks is quite an important thing to just check. Um, but that's definitely a differential to keep in mind. And then your biggest one is meningococcal septicemia, something which I just want to go over with you all because it is an important difference. A non blanching rash. So a rash that you basically put the glass like a glass a drinking glass on, and you try to get rid of it by pressing on the skin. It doesn't go away. That doesn't always mean it's meningococcus septicemia. What that is basically telling you is blood has collected under the skin, and when you've tried to put the glass on, it's not going away. The reason why we do that is because if you had a rash, which looked very much like some kind of bruising or something and you put a glass onto it and it went away, then you're not dealing with blood that's pulling under the skin. You're just dealing with some kind of rash, which could be anything is quite telling that there's a clot. There's an actual curricula ation problem or blood is literally leaking out the blood vessels, which is a much more sinister kind of picture You're dealing with them. I did have a thing for questions just because there's a lot to kind of go over in pediatric pediatric history. Uh, rule in a couple of questions. I have tried answering them while the questions came, Uh, one. Really nice question. I was going to reply to you. You know who, Uh, if you messaged me, you know who you are. Um, question is, how do you screen for abuse without coming office offensive in the actual history? I presume that's actually the actual history, so just kind of giving them a warning beforehand. So saying this is something that we always have, So I would I would relate it back to the bruising So, you know, saying this is something that we have to ask all parents when they have a child coming in with bruising. But has social services ever been involved in your child's care? They might, because they might come off offended. But the best way to kind of back yourself up is to say I'm really sorry, but it's it's something that we are required to do. You can Oh, uh um, I yeah, you can do that. Or you could also just be like, how are things at home and just go quite nice. And if it if it is something that the examiners meant to say and you have mentioned as and you have asked in some way or the other, they will say it. I might retract what? I've kind of, uh, you know, I said, if if ask if you're asking about home and how things are back home, you kind of our screening for any issues that related there, Anyway, it's something to keep in mind, maybe kind of. After you've taken the history to state to the Examiner, I would like to check that social services haven't have not been involved in this child care. But even if you're asking in the history so long as you're asking it sensitively and pre warning them, then there's nothing necessarily wrong the actor, I think wouldn't come across as quite resistant to that sort of question. Um, so long as you state this isn't something which were, you know, discriminating you against, we have to ask everyone this question. Um, yeah, that is a really big good tipper. Any history, actually, including psych, especially because there are weird questions for psych. Um, just signposts, if you're not sure, just be like, oh, we have to ask this question to everyone and then ask it. So I think the the actor will be, Yeah, the actors quite, uh, forgiving. In that sense, they wouldn't kind of come across in an an aggressive way, so long as you've justified why you need to ask it Does that help? I hope that helps, but obviously they can send another question, if if not just message saying if we helped just keeping in, uh, one more question, Uh, what what are some causes of non blanching rashes? Cause of non blanching rashes? Oh, gosh, That's a good one. I mean, you're looking at all the infectious diseases. So measles, German measles, um, you can be dealing with impetigo. HSV six. I mean, it's the list is endless. It depends on the rash that you're dealing with. And I will do a teaching session on how to ask questions about a rash, or even if you have to examine one. How to describe a rash you're looking at, um, but non blanching rash. You're you're thinking some kind of infection infectious cause of it Or even possibly, uh, you know, your your rashes that are caused by chronic conditions such as, um, dermatitis have better for Ms you know, your Erythrocin um a caused by them starting a new medication. You know, I could go on. It's the vast array of dermatology and all that's included in it. Yeah, the other. The other question I got directly was whether the history normally is from a parent or a child, and I think answer would be it could be both. I don't think it's going to be very young child. That would probably so. They actually gave us a child in our in our actual station, but she was, I think 15. So I would I would say that probably if they wonder turn, you know, guarantee they're gonna have a parent overturn. It's fair game. They probably they will have a child actor in that situation. Um, and that was the actual station where I'd asked a full history just for context for people. I'd asked a full history about some abdominal pain. She was diabetic. I didn't really know what was causing it. I had asked, Are you are you controlling your diabetes? Well, and she said yes. As soon as I asked. Oh, do you have any idea what could be causing it? She said, Oh, I It could be that I stopped my insulin a couple of months ago. So this is why I say I strongly urge you definitely remember to ask about it. Okay, right. So moving on to obstetric history. Same thing again. I've used the same kind of format. Um, you want to explore the symptom do relevant system of use and I've put a specific the specific one up, always to us, which is your guy new system of you and that kind of will go into the gynie history that I'll go through later on by Used to use the four ps. So your first p any pain? Ok, this could be pain. Um, when they have their period So dysmenorrhea this could be pain When they're having sexual intercourse, pay it just general pain around the kind of abdominal area. Once you establish what is causing it when you're presenting, obviously try to use the actual medical language. So this is dyspareunia or this is, uh, dysmenorrhea. Then you have your P V discharge. So per vaginal discharge and you you might want if they say Oh, yes, I am then asking, you know, the color, the consistency. Is there a smell to it? So you're thinking there might be an S t i or or something like an infection going on your next P, which is any P V bleeding and then your final P, which I always like to ask your preeclampsia symptoms. So any headaches, any visual disturbances, any pain in the tummy, you already ask it. But those are the kind of symptoms you get preeclampsia and I've cut off the last bit. Only that that was that I can't see the kind of end bit because I've got the pictures there. Um, then go into your ice. And from that point, you can then do your more specific things for an obstetric history. So the current pregnancy? Yeah. How is the pregnancy going? So any I would think Any problems at their booking scan? That's the most important tell sign whether something is going right or wrong on the pregnancy. So they do scans at that, uh, at that appointment. Sorry, I I should correct that. Any problems identified at booking appointment? Sorry, That shouldn't be booking scan booking appointment. So they do bloods, they do scans, and they do obs your BP and your urine dip. Uh, sorry. I can't read that last, but do they know? Yes. And of course, uh, this is the big red flag. Juan. Don't forget to ask about their recess status. That's really important. And moms and moms will know it. And if they don't, then it's something that you can mention. You know, when you're presenting, I'd like to check their research status. Then I'd like, and then I go into the obstetric history. Okay, so I used abbreviation gm. See, it's very easy to remember because G. M c so g is your gravity and parity. So asking them how many pregnancies have they had and then asking possibly how how many have they actually carried to term? So how many have been live deliveries? In effect? Um, that ties into your M. And I think about all the kind of ways in which someone could possibly lose a pregnancy. Now, this is, uh, something that again you really need to be sensitive and prewarn beforehand. So something like I I'm you know, Sorry, I have to ask this, but have you had any miscarriages? And this is different to when I said you shouldn't say sorry for asking about smoking because, you know, someone's lost a pregnancy. That is something you know, which will have affected them a lot. So, you know, being sensitive is important. So they had any miscarriages. Have they had any ectopic pregnancies? And then have they had any terminations? And then you'll see will be Children. So the Children they have at the moment And were there any issues when they were pregnant with them? And when they had the when they had the delivery with them and then you want to ask about the same thing again? Past medical history, drug history, family history and social history. And this is kind of a form that I used to use for most of my obstetric kind of presentations. So this is Mrs Jones, a 30 year old female, uh, pregnant female who is at X weeks to station gravida x parity X. With this being, her pregnancy she is presented with it gives the whole background of their pregnancy. We're not even, you know, skipping a beat. So they're pregnant. Where there are in the pregnancy, how many they've they've had before and then which pregnancy is this? It's only four things in the presentation, So it's pretty click up. So going to just go through the like, common kind of stations that come up mhm. There we go. So abdominal pain. Most of us kind of saw this one coming so obstetric cause of an abdominal pain. It will very much depend on as well, like your differentials, where they are in their pregnancy. So is it first trimester or is it third trimester? If it's first trimester, you're thinking a topic. Is it a miscarriage? If it's at the end of their pregnancy, you're thinking, Could this be placental abruption? Could this be preeclampsia? Could this even be labor? Or could this be some kind of infection like chorioamnionitis? Okay. And then you have these more niche ones that I don't think that they would throw in, but a differential if you want to throw it in round ligament pain. So, um, this is, uh, something that pregnant females get very commonly. Obviously, when you're releasing hormones that allow elastin to be a bit basically allow most of your, uh, kind of organs and muscles and tissues to be more elastic, it cause a lot of stretching, and this can disrupt certain structures and cause pain and effect. Um, round ligament pain is quite common, and you also can get something called synthesis pubis dysfunction. That's literally just a pain that you get right over the symphysis pubis, and it can often radiate kind of to the groin sort of area. That's the very common presentation of it. So those are your step obstetric causes. You want to rule out possible gynie causes. So any fibroids, pelvic inflammatory disease. So that's basically an S t. I or sometimes UTI, but usually an S t I. That's basically gone up, and it's now kind of a bilateral pain. It's it's not systemic, but it's it's spread a bit more ovarian torsion, or you can get other kinds of varying problems like a very in rupture. But ovarian torsion is a big one and then your general cause of abdominal pain. So ones that they like to throw in is a UTI in a pregnancy and appendicitis and a pregnancy. So don't ever forget those could be differentials. And as I said, key to the obstetric cause is when they're getting it, So are they first trimester while they third trimester? Yeah, that's our first trimester and second trimester. Um, those usually a miscarriage neck topic. Um, and the third trimester is, you know, for once, PV bleeding is the other, um, common presentation. That kind of goes hand in hand with the abdominal pain. You just need to know which which conditions cause abdominal pain with PV bleeding and which ones cause just PV bleeding. But no abdominal pain. So your 1st and 2nd trimester you're thinking, is it a miscarriage is an ectopic, and if it's not if it's neither of those. Most likely, it's something called an implantation bleed that usually only occurs around about four weeks into the pregnancy. Sometimes they don't even know that they're actually pregnant. Um, and it's literally just wants the, uh, percentages implanted. They then get a bit of the, um, blood that comes from it, uh, passing out. And then you have your third trimester, which is either labor placental abruption where you get the pain with it, or the other two is placenta previa or vase a previa. The just a differentiate between all of these because PV bleed is a very common one that comes up your three big ones for third trimester. It's usually going to be third trimester. That comes up because it allows you to to test these different fundamental principles. Placental abruption. You get pain and PV bleeding. Placenta previa. You just get P V bleeding. No pain. The other thing that comes alongside it is you get lots of bleeding and they often go into, um, kind of like shock like symptoms. Okay, um, you can get that placental abruption, but you get less bleeding with the pain, though, is is quite excruciating. And if it's like an acute history, they might also describe what you felt on exam. So placental abruption. You feel a very firm, uh, firm uterus. Okay, it almost feel like, um, like, solid. Okay, if it's placenta previa, the the uterus is usually, like, a bit more. Um, uh, palpable, less firm, um, trying to think of the best way to describe it. But firm firm uterus is placental abruption. Vays a previa. That's when you have some bleeding, Okay. And the most common thing that comes with it is, uh is very difficult to tell on a history, but they might throw in a C t G, which is a monitoring device they use on babies. They might tell you that this investigation has come back, and it's it's showing a bradycardia for the baby. Okay, that is always telling that it's Visa previa. And that's, uh, it's basically a medical emergency. Um, the all three are technically medical emergencies, but vase a preview is, um, very bad, because most of the time it means you've got minutes before the baby is going to die in neutral. So, um, that's one which you should always have as a differential, even if you're certain it's placenta, placenta abruption or something. Okay, so we've done obstetric Any questions on those? Um, there is a question regarding Did you say shock is coming in abruption or previa? Shock is common in previous, but you can also get shock symptoms and placental abruption. Um, previous, you'll get vast amounts of blood, but they'll be, uh I mean, they won't have any pain with it, whereas abruption you get less bleeding, but large amounts of pain. Um, that's the most important thing to kind of identify in the history. Um, the shock kind of come what comes with it. It more just tells you whether their clinically, uh, deteriorating quicker compared to other patient's, whether they need, you know, a more emergency like C section. Compared to you know, others. Does anyone have any other questions? And I know we've covered quite a bit, but if you want us to go over anything as well, just let us know. Cool. Ok, so gyne history kind of the same sort of things that you're asking. It's just kind of the reverse, really So again, gynie system of you and then after even ice. I used a thing called Mosque. Okay, um, so you want to check their menstrual history? So that's kind of just asking him. Basically, you're taking a full history about that kind of menstrual cycle and effect. So how long does it last? When When was the, uh, their last period that they had, um if you're dealing with a child Oh, in fact, even an adult, it is important to ask about the men arc. So when did they first have their? When was their first pregnancy not pregnancy, their first period. Um, And if you're dealing with someone who's maybe in their late fifties, you may also you want to ask about menopause as well. So, have they had the menopause yet? If so, when was it? And that ties into kind of the cancer, Uh, risk factors in in gynecology. So if someone, I I used to think about it as and it's gonna write my brain because my gynie isn't isn't the best. But if someone has more exposure, I think of it as almost like a timeline. The opportunity for estrogen to be around, uh, in a person's life. Okay. If someone has an early men arc. Okay, so that, uh, they're menstruation began when they were 10. That means estrogen was releasing when they were 10. Okay, that's a bit earlier for for some girls than normal. In fact, I'll actually say that this six OK, six is when they had their first period. That means that estrogen was releasing when they were six very early. Okay, because that Asian is going to be around for a couple more years. They're more likely to have something like an endometrial cancer, okay, or even breast cancer. It's all to do with exposure to certain hormones, um, in a person's time, uh, in a person's life, if they have a late menopause. So let's say it's 65. Okay, very late. Then That means that most people have a menopause when they're 50. So this person had an extra 15 years to have Eastern around in their bloodstream, which increases their risk again of having a possible cancer. So those are quite important kind of questions to ask if you're thinking about cancer diagnoses. Um, Riz McCann, you just quickly check because I don't want to, um, say something wrong, But can you check which cancers. It is that if you have unopposed estrogen, it puts you more at risk of. So if you have an early men are correlate menopause, which cancers? But I'm pretty sure it's endometrial and breast, you know? You know what? I'm pretty sure you're for PT Ra Vision. Does anyone else wanna give a Oh, here we go. Here's a question for people. Yeah, if you don't know, that's fine. Uh, we'll answer it, but just putting it on the floor now. Yeah, I don't I'm gonna one answer. Anyone else wanna give it a try? It's okay if you're all ovarian, okay? It might be a right. So I'm going to, um I've got people saying breast and ovarian breast and endometrial. Um, someone said Ronan is right, I think. Okay, well, we'll we'll all be on the consensus. That's your homework. OK, guys, So you can go away and search that up, but it cause it predisposes you to some cancer out there, Okay? It's one of the four, either, uh, cervical, endometrial, ovarian or breast. It's two out of those four. I know that much. So, um yeah, so I I know exactly. Breast, Uh, and I feel like the other one. I I It might not be an end. I kind of want Is it, um, you know, ovarian and not endometrial. Um, I'll give the reason you can. All you can all go away and search that up, but still important questions to ask about cycle length. We've already discussed that. And then you want to ask, um uh about well, regularity. So they are they getting their periods regularly, and then character of the periods? That's very important. So the only things that people can, uh um we can, uh, we like to ask about kind of periods. Is is there any pain during them? Um, is there any menorrhagia so heavy bleeding? Um and yeah, I think I think that would be kind of the t, which are most important for character. Really? By the way, I think answer would be endometrial and breast. But I kind of also wanted to say thank you for being so responsive. We know you're not sleeping right now, so Well, then, good to her. Um, so going on 20 obstetric history, you know, we already kind of cover that too. The gm see? Yeah, follow that format. Um, again, you know, context is key. If you don't have as much time in the exam, you know, it's not important to ask about, you know, gravity parity, miscarriages, terminations. You know, you've got to use your time effectively. But these are ways to kind of, you know, get your brain going on the on the day s so sexual history. So this is very important, guy. Any history it links basically to your pelvic inflammatory disease or U S T. I s So chlamydia, Gonorrhea, Uh, you know, the list goes on. Um, so that's going to be Are they sexually active? At the moment, have they had a sexual partner in the last I'd say six months. That's usually, uh, the time frame I go with. Um, you have to be sensitive with the questions that follow with follow. Or even before you've asked that you should technically give a heads up. Okay, I'm going to ask about your sexual history, If that's all right, then, um, asking about the type of intercourse that kind of that is quite important. Um, and that that usually kind of suffices. Um, then going on to your see, you can ask about contraception and sexual history, but I like to think about C is the last bit to to mosque. Um, were they using contraception? And this includes both hormonal contraception and barrier contraception. So, asking about the team and asking about the cervical smear history If they're over 25 then yes, they will have a cervical smear history. If they're under 25 then, um, they won't have started yet. Um, and then you can again go onto your whole past medical, drug, family, social history and so on. Just going to social history. Um, kind of for some context, social history is quite useful for the presentations, like secondary amenorrhea. Um, so they were having periods, but now they've stopped. And that's usually, um, uh it stopped for I believe it's 12 months. Um, because a very common cause of this can be either. You're very stressed. You're heavily exercising or even your diet is quite poor. Um, so as well as having all your other causes that can cause secondary amenorrhea, a very common one is is their actual lifestyle affecting it somehow? So common histories or presentation like stations. Really? You've got your pelvic pain. So again you've got your gynie so public inflammat disease, ectopic ovarian problems, endometriosis, Um, which just for kind of the buzz things that they throw in in the history you're usually looking at something called Deep Dyspareunia. That's very classic, classic symptom that comes with it so deep. So you have something called superficial dyspareunia and dyspareunia, meaning pain on sexual intercourse, and you have another one called deep dyspareunia. Superficial is the pain is kind of on the surface, okay, it feels like it's on the surface. Deep is it feels like it's a more internal pain that you're experiencing, and then your classic kind of examination findings will be like, you know, you get like a boggy you to It's So you even had a look during the vaginal exam and you've seen kind of evidence of endometrial endometrial tissue. And then another one, which is very common females, is something called Middleschmertz. It's they always like to throw it in, sometimes in the Pts. But the classic history to that is it's, um, an overview trying to rack my brain. But I'm pretty sure it's ovulatory pain. So they get it's cyclical and it happens on day 14 of their cycle. Um, yeah. Uh, yeah. And then yeah, uh, you can tell I'm not going. I'm not a gynecologist. Guys. My gynie is really not up to date. So correct me if I'm saying anything wrong during this, uh, but trust me, he knows how to take a really good guy. Any history? Yeah. Uh, and then you have your urological causes, so a UTI, um, possible pylon if itis um uh and then other kind of neurological conditions that were late and then gastrointestinal. So that's all your GI conditions and effects. So, uh, all the way from your diverticulitis to your IBD To you I b s. Yeah, Another one is P v bleeding. So you you can see the trend they ask about in obstetric history is they also asked about about in gynie histories. And there's a lot of crossover PV bleeding. It's just it's really important in when you're asking about the like, the character of it and when it's happening. Uh, sorry. The character of it. You should be really, um, differentiating between when is that PV bleeding happening? So is it when they're expecting their period to happen, so it's more heavy than normal manufacture. Is it, uh, in the middle of their period when they weren't expecting it into menstrual? Is it after they're having sexual intercourse so postcoital or have they already had their menopause? And they stopped having the booze, and now they're bleeding again. Okay, so, post menopausal, you're really only thinking about two differentials. Two big ones. Either. It's endometrial cancer, and basically it's endometrial cancer until proven otherwise in the actual, um, physical world. Okay, we always treat it as endometrial cancer until we prove it's not. If it's not that, then most likely it's something called atrophic vaginitis, and the basic pathology of this is the estrogen has absolutely crashed after their menopause. Once your estrogen drops rapidly, the lining of the cervix uh, sorry. The vagina can atrophy, and you can start getting pain and the even can start bleeding or pain isn't the usual symptoms. They say that they have itchiness, and it feels dry around the area, and they also have the bleeding. And sometimes it can be painful postcoital. It's either trauma. Often polyps can cause it so cervical polyps, service itis or vaginitis so any inflammation of the vaginal cervix and then other possible causes, or something that you always want to rule out, which you can rule out in a speculum exam is something like a cervical cancer men arancha. Usually it's either five boys or endometriosis, Um, and then another one to just consider is pelvic inflammatory disease or P I d. And then into menstrual you have. It's either you're dealing with a service itis or vagin itis something called an ectropion. Um, so an ectropion is basically when your, um, your uterus as the, uh, period period as the cycle goes on. So after ovulation, your lining around the uterus obviously changes. But that changing that's been occurring has actually extended too far, and it's extended actually into the into the vagina area. So you have a a line call the transformation zone. Um, you can search up on Google if you guys want, but you have your uterus and then you have your cervix. The transformation zone is a particular area right in the middle of that, which basically demarcates what is lining of uterus and what is lining of vagina when you have something called a neck Tropea in. That basically means that that lining that's normally in the uterus, that's very different to the lining that you get in. The in the vagina is extended too far, and it's now actually into the vagina. Um, because that lining is very different and not used to that kind of, um, area. Once you start having menstrual shedding at the end of your, um, your pit or your cycle, you'll often start getting bleeding quite early on or before you're expecting to have your period. Really, Um, you have the next one, which is a secondary amenorrhea. And as I mentioned, a very common cause is just your kind of social aspects of your stress or exercise or diet is wrong. Um, one which you always want to rule out, is pregnancy. Um, so any female that comes in who has secondary amenorrhea you always do a pregnancy test and then other causes things like PCOS um, so polycystic ovarian syndrome, premature ovarian failure that's more like your 35 year old or 40 year old. That's all of a sudden getting menopause symptoms, um so menopause symptoms is things like flush flushing of the skin. They'll start getting really hot and sweaty. Um, they might even get changes around the vagina, which is like, drying or itchiness. Um, yeah, hypothalamic amenorrhea. It's just a general term for saying there's something wrong with the hypothalamus which normally releases your, um, the first stage of your, um uh, menstrual hormones. Um, and then another one, Cushing's. But, um, yeah, that normally comes with your classic Cushing's, uh, symptoms. Okay, so that is the whole talk. I'm really sorry that I went through that quite quickly, but we had a lot of ground to cover. Um, does anyone have any questions? Any ideas? Concerns, expectations? Anyone? Uh, there was a question one second. Um, I am gonna stop your share screen and share mine now. Yeah, that's fine. I should I'll keep the recording going until we go. Yeah, that's fine. Uh, right. Um, and the question we had was how do you put all of these into a seven minute history? Yeah. Okay. So the reason I've not given you this with the expectation that you're going to walk away today and you know perfectly take a piece. History or gynie history. What I've tried to do is give you a format that is really helpful for you to structure your history taking. And then when you're doing your seven minute histories, when you're practicing with people something having that in the back of your mind But, uh, you know, finding your footing with it. I mean, we've we've covered a lot today. Um, but the most important thing is, if you have a particular presenting complaint when you're outside your station, you kind of know how you know how you're going to start tailoring your history to it. So it's you're not going to include everything the is in that, you know, a whole form at you're going to pick and choose. But so long as you know, for Pedes, you've got the B f g d. In the back of your mind, you might be like, Oh, yeah, I don't need to really ask about birth. Know feeding that will be important Growth. I'm not really that first development. I might ask about their schooling or something so you can pick and choose. Um, the best thing I can say is your if it's for if it's an acute history, okay, that that kind of speed that you need is just going to be You're gonna ask about your presenting complaint. Okay, You're gonna ask a quick system of you and I would literally just stick with the general system of you. So any weight weight changes, any fevers, any malaise, any appetite changes. Once that's done, I'm probably not going to go back to it. Then when you're asking about kind of your whole past medical, drug and all sorts past medical history, I'm not even going to ask about specific medical conditions. I'm just going to say any medical conditions that you're diagnosed with no fine in the four minute history is they're not going to hide anything in the seven minute histories. They don't really hide things, but they won't. They won't volunteer stuff unless you're kind of pushing them a bit. The most important thing I can state is when you're doing a system of you that's not a substitute for you. Just, uh, to ask about all the symptoms it possibly could be. It's for you to just rule out specific things. So when you've asked about present a presented complain your your next question that should follow. It should be any other symptoms, and then they might volunteer something else. Then, when you've asked a bit about that, any other symptoms? And until they said no to that question, you shouldn't really stop that. Because otherwise, you're just kind of shooting in the dark when you're asking all these questions in the system of you, If you guys want you can, uh, meet your mic if you have any questions. Um, we have a question. Would it be possible to make a cheat sheet with things you must ask for each history? Yes, we are on it. Um, yeah. No. No worries. Um, we'll we'll get it. We'll get it to you guys sometime. Um, yeah. Mhm. Any other questions? Mhm. That's fine. You're welcome, guys. Um, if anyone is going to stay for me to quickly go through the talk from last week, then please do. Um, but other than that, you're free to go. I hope that was helpful. I can stop recording