history taking for osces
TRANSCRIPT
History Taking for OSCEs
Clarissa GurbaniYear 3 Medical StudentUniversity of Manchester
General tipsFollow the Calgary-Cambridge Framework!Score points with a solid introductionBegin by asking open questionsShow that you’re interested
◦ Posture – lean forward◦ Good eye contact
Remember ICE:◦ Ideas◦ Concerns◦ Expectations
Summarize at regular intervalsDon’t miss crucial signposts!
Introduce yourself!‘Good afternoon, my name is Joe Bloggs and
I’m a 3rd year medical student. I’ve just been asked to take a history from you today, is that alright?’
‘Before I continue, can I just confirm your name and date of birth?’
‘I just want to let you know that this interview will be kept confidential between me and the medical team involved in your care.’
Your introductionIf there is hand gel – use it!State who you are and your year
of studyConsent and confidentialityCheck the patient’s name and
DOB against their wristband – older patients may be confused. Do it subtly so as to not offend the patient!
Calgary-Cambridge Framework1. Presenting complaint (PC)2. History of presenting complaint
(HPC)3. Past medical history (PMH)4. Drug history (DH)5. Family history (FH)6. Social history (SH)7. Systems review
PC1 sentence in the pt’s own wordsDon’t interrupt pt’s opening
statement!Build rapport from the very
beginning
PCStart with either:‘How are you feeling today?’‘What has brought you into the
GP practice?’‘Could you tell me what brought
you into the hospital?’
HPCRespond to what the patient has
told you!Obtain a timeline of events
◦When it began (i.e. acute vs chronic)◦When pt first sought medical advice◦‘Is this the first time this has
happened?’◦‘Does it get better?’ (i.e. remittance)
HPCIf there is pain, remember SOCRATES:
◦S – site◦O – onset ◦C – character◦R – radiation◦A – associated features (e.g. nausea,
vomiting)◦T – timing◦E – exacerbating/relieving factors◦S – severity (compare with worst pain ever
felt)
HPCDifferentiate pain according to
symptomsE.g. chest pain:
◦Cardiac – central, crushing, radiating to jaw, neck and left shoulder (angina, MI); tearing, interscapular pain radiating to the back (aortic dissection) etc.
◦Pleuritic – worse on inspiration/coughing
◦Musculoskeletal – worse on certain movements (e.g. turning to the side) and can usually be localized to a specific area
HPCFull list of signs and symptoms (S+S)E.g. in the respiratory system
◦SOB (exertional/at rest)◦Pleuritic chest pain◦Weight loss◦Cough (dry/productive)◦Sputum (colour, quantity)◦Nocturnal cough (Asthma, ? cardiac
asthma in congestive heart failure)◦Reduced exercise tolerance
HPCAlso bear in mind:
◦Disrupted sleep patterns (e.g. symptoms worse at night? – asthma, peripheral arterial disease etc.)
◦Affecting activities of daily living (ADL)?
PMHAsk about common medical
conditions:•Hypertension•High cholesterol•Diabetes mellitus (type 1 or 2)•Asthma (ask also about chronic rhinitis and eczema – triad of allergy)•COPD•IHD (angina, MI)•CVS (TIAs, strokes)
•Arthritis •Orthopaedic problems•Liver disease•Chronic kidney disease•Bowel problems (constipation, diarrhoea)•Urinary problems (e.g. benign prostatic hyperplasia)
PMHPrevious surgeriesPrevious hospitalizationsTry to obtain timeline, e.g. ‘When
were you diagnosed with asthma?’ – helps when you are looking through the patient’s drug history
DHDosageTiming (od, bd, td, qds, prn)OTC medicationsRecreational drugsDrug allergies!
FHDon’t be afraid to ask!Approach with tact – ‘Does
anyone else in your family have this condition?’ or ‘Do you know of any other health conditions that may run in your family?’
Important as many conditions carry genetic components
SHSmoking
◦‘Have you ever smoked?’◦‘When did you start?’◦‘How many do you smoke a day, on
average?’◦‘Have you ever tried to quit?’◦1 pack year = 20 cigarettes/day for 1
year
SHAlcohol
◦‘How much alcohol do you drink a week?’
◦Maximum recommended no. of units – 21 for men, 14 for women
◦If pt can identify a certain time he altered his drinking habits, try and identify a trigger
◦1 pint of beer = 2 units
SHEmployment statusHome situation
◦‘Who’s at home with you?’◦For elderly patients – ‘Do you get
any help at home?’◦Family support
Diet and exercisePets
◦E.g. for atopic conditions like asthma
Systems reviewNot an exhaustive listAsk what you think is relevant to
pt in light of:◦Demographic (e.g. age, sex)◦PC and PMH◦Family history
You may uncover another PC that the patient may not have mentioned!
Respiratory systems reviewDyspnoea (exertional/at rest/progressive)Cough – productive/dry/croupy/nocturnalSputum – colour/purulent/amountWheeze (expiratory)Stridor (inspiratory) – upper airway
obstructionHaemoptysis – frank, or in sputumPleuritic chest pain – worse in
inspiration/coughingDecreased exercise tolerance
Cardiac systems reviewAngina DyspnoeaOrthopnoea (measure by pillows)Paroxysmal nocturnal dyspnoea
(PND)PalpitationsSyncope/pre-syncope
Vascular systems review6 P’s
◦Pallor◦Pulseless◦Perishing cold◦Pain◦Paraesthesia◦Paralysis
Claudication UlcersVaricosities
GI systems reviewHeartburn NauseaVomiting (coffee grounds/frank blood/bile)Weight lossAbdominal pain (?guarding)Altered bowel habits (e.g. increased frequency) IndigestionDiarrhoea ConstipationPR bleedingTenesmus (straining) Incomplete evacuation
Genitourinary systems reviewHaematuriaBurning/scalding pain on
micturitionFrequencyHesitancyIncontinence
CNS systems reviewHeadachesVasovagal episodes (fainting)DizzinessVertigoWeaknessVisual symptomsConfusionPoor memoryAltered reflexesAltered sensationDifficulty with complex actions
(dysdiadochokinesia)
Musculoskeletal systems reviewArthritisPain while walking (differentiate
from claudication – comes on at a fixed distance, worse when walking uphill, does not radiate, usually localised to back of calf but can affect gluteal muscles and posterior thigh, settles within 10 to 15 minutes of rest)
Conclusion Summarise againMake sure you have obtained
ICE, if not ask the patient explicitly – ‘What did you hope to get out of this interview?’, ‘What do you think these symptoms might suggest?’
Ask the pt if he/she has any questions
Presenting your findingsCome up with 3 differential
diagnoses◦1 must be sinister e.g. malignancy◦Be able to explain why these are
your DDx◦Bear in mind further investigations
you may do to confirm a diagnosis if the examiner asks
If you panic, go back to your surgical sieves!
Surgical sieve 1TraumaInfectionMetabolicAutoimmuneNeoplasticEndocrine
Surgical sieve 2Psychogenic IatrogenicIdiopathicCongenitalDestructiveProliferative
To finish your stationThank the patient and the
examiner Wash your hands again
Final tipsAppear confident throughout If your mind goes blank,
summarize and ask the pt to add on – ‘Is there anything you feel you might want to add on?’
Practice taking histories on wards and time yourself
Clerk patients (if the FY or consultant is willing to let you to – ask for permission!)
Present your histories to your consultants
Thank you!