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!