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History Taking for OSCEs

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History Taking for OSCEs

  1. 1. History Taking for OSCEs Clarissa Gurbani Year 3 Medical Student University of Manchester
  2. 2. General tips  Follow the Calgary-Cambridge Framework!  Score points with a solid introduction  Begin by asking open questions  Show that you’re interested ◦ Posture – lean forward ◦ Good eye contact  Remember ICE: ◦ Ideas ◦ Concerns ◦ Expectations  Summarize at regular intervals  Don’t miss crucial signposts!
  3. 3. 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.’
  4. 4. Your introduction  If there is hand gel – use it!  State who you are and your year of study  Consent and confidentiality  Check the patient’s name and DOB against their wristband – older patients may be confused. Do it subtly so as to not offend the patient!
  5. 5. Calgary-Cambridge Framework 1. 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
  6. 6. PC  1 sentence in the pt’s own words  Don’t interrupt pt’s opening statement!  Build rapport from the very beginning
  7. 7. PC Start 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?’
  8. 8. HPC  Respond 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)
  9. 9. HPC  If 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)
  10. 10. HPC  Differentiate pain according to symptoms  E.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
  11. 11. HPC  Full 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
  12. 12. HPC  Also bear in mind: ◦ Disrupted sleep patterns (e.g. symptoms worse at night? – asthma, peripheral arterial disease etc.) ◦ Affecting activities of daily living (ADL)?
  13. 13. PMH  Ask 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)
  14. 14. PMH  Previous surgeries  Previous hospitalizations  Try to obtain timeline, e.g. ‘When were you diagnosed with asthma?’ – helps when you are looking through the patient’s drug history
  15. 15. DH  Dosage  Timing (od, bd, td, qds, prn)  OTC medications  Recreational drugs  Drug allergies!
  16. 16. FH  Don’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
  17. 17. SH  Smoking ◦ ‘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
  18. 18. SH  Alcohol ◦ ‘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
  19. 19. SH  Employment status  Home situation ◦ ‘Who’s at home with you?’ ◦ For elderly patients – ‘Do you get any help at home?’ ◦ Family support  Diet and exercise  Pets ◦ E.g. for atopic conditions like asthma
  20. 20. Systems review  Not an exhaustive list  Ask 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!
  21. 21. Respiratory systems review  Dyspnoea (exertional/at rest/progressive)  Cough – productive/dry/croupy/nocturnal  Sputum – colour/purulent/amount  Wheeze (expiratory)  Stridor (inspiratory) – upper airway obstruction  Haemoptysis – frank, or in sputum  Pleuritic chest pain – worse in inspiration/coughing  Decreased exercise tolerance
  22. 22. Cardiac systems review  Angina  Dyspnoea  Orthopnoea (measure by pillows)  Paroxysmal nocturnal dyspnoea (PND)  Palpitations  Syncope/pre-syncope
  23. 23. Vascular systems review  6 P’s ◦ Pallor ◦ Pulseless ◦ Perishing cold ◦ Pain ◦ Paraesthesia ◦ Paralysis  Claudication  Ulcers  Varicosities
  24. 24. GI systems review  Heartburn  Nausea  Vomiting (coffee grounds/frank blood/bile)  Weight loss  Abdominal pain (?guarding)  Altered bowel habits (e.g. increased frequency)  Indigestion  Diarrhoea  Constipation  PR bleeding  Tenesmus (straining)  Incomplete evacuation
  25. 25. Genitourinary systems review  Haematuria  Burning/scalding pain on micturition  Frequency  Hesitancy  Incontinence
  26. 26. CNS systems review  Headaches  Vasovagal episodes (fainting)  Dizziness  Vertigo  Weakness  Visual symptoms  Confusion  Poor memory  Altered reflexes  Altered sensation  Difficulty with complex actions (dysdiadochokinesia)
  27. 27. Musculoskeletal systems review  Arthritis  Pain 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)
  28. 28. Conclusion  Summarise again  Make 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
  29. 29. Presenting your findings  Come 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!
  30. 30. Surgical sieve 1  Trauma  Infection  Metabolic  Autoimmune  Neoplastic  Endocrine
  31. 31. Surgical sieve 2  Psychogenic  Iatrogenic  Idiopathic  Congenital  Destructive  Proliferative
  32. 32. To finish your station  Thank the patient and the examiner  Wash your hands again
  33. 33. Final tips  Appear 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!)
  34. 34. Thank you!

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