History taking OSCE
Card Set Information
History taking OSCE
All the diseases
Breathlessness, loss of consciousness, palpitations, ankle swelling, nausea, vomiting, sweating
Cough, wheeze, haemoptysis
Heartburn, GORD, pain related to eating
Weight loss (also appetite loss, diet if true), night sweats
Notes - hyperlipidaemia, hypertension, diabetes, angina
Onset and activity
Cough + sputum, wheeze, chest pain, haemoptysis, fever, PND, orthopnoea, oedema
Weight loss, anorexia, sleep disturbance, night sweats
Notes - occupation, pets, travel
Establish circumstances of fall - time, place, activity
Loss of consciousness/confusion on recovery
Any focal neuro cfs before, e.g. vision/power/face/dysphasia
Exclude mechanical cause of fall/any mobility aids
Was the fall witnessed
Any injury after fall?
Hx of falls, seizures, angina, SOB, anxiety
Full smoking history
: amount, reasons, attempts, barriers and benefits
Advice and support
Clarify symptoms and where things are sticking
Progressive or intermittent?
Solids, liquids or both?
Pain? Coughing? Choking? Gargling?
Neuro - limb weakness, tiredness after chewing, speech
Rheum - pain, stiffness or swelling in any joints
Weight loss, anorexia, lethargy anaemia
Hx of GORD, peptic ulcer, stroke, MS, malignancy
NSAIDS, indigestion tablets taken?
Appearance, volume, projectile, blood (especially if present in first vomit).
Occuring with meals? Relieve any pain/nausea? Effortless?
Abdominal pain, weight loss, appetite change, constipation, diarrhoea
GORD, ulcers, pancreatitis, gallstones or angina
Alcohol, smoking and foreign travel
Acute or chronic? Who noticed it?
Pain? Pale stools/dark urine? Bowel habit? Pruritis? Fever? Night sweats? Weight loss? Nausea/vomiting?
Gallstones, liver disease, IBD, diabetes, blood transfusions Hx?
Unprotected sex? Past STIs?
IV drug use, tattoos, alcohol, foreign travel
Nausea/vomiting, fever, anorexia, bowel habit change, FOB, dysuria
Trauma, gallstones, diverticulitis, IBD, HIB, CV disease
Alcohol, smoking, foreign travel
Altered bowel habit
Frequency? Volume? Character? Colour- blood/mucous?
IBD/IBS, ulcers, abdominal surgery?
Laxatives? opiates, gluten sensitivity?
Family - bowel cancer, IBD, coeliac disease
Alcohol, tobacco, diet, foreign travel, contact with diarrhoea, STI
Volume? Frequency? Clots? Pain? Pain on straining?
Colour,? Blood mixed/separate?
Lethargy/SOB for anaemia
Weight loss, anorexia, fatigue for malignancy
History of rectal bleeding, IBD, bowel surgery
Family - polyps/bowel cancer
Reassure of confidentiality
: Last time, gender, regular/casual, recent activity, where did they meet?
: Type of sex, gave/received
: Type and problems
: Both patient and partner
Any sex overseas?
Itching, sores, dysuria
: size, site, onset, duration. SOCRATES
Discharge, bleeding, skin/nipple changes
Tiredness, fever, weight loss, chest/back pain
Related to menstrual cycle?
Hypertension, cardiac disease, obesity
Family - male/female breast cancer, ovarian
Alcohol, smoking, early menarche, nulliparity, late menopause, HRT, obesity
Nausea, vomiting, aura, diplopia, photophobia, fever/chills
Weight loss, rash, neck pain/stiffness, myalgia, lacrimation, altered consciousness, paraesthesia/power
Worsened by - prone/supine, caffeine, alcohol, dehydration, stress, eye strain, hunger, lights, menses, foods
Hx of headache, migraine, travel sickness, trauma, IC lesion
NSAIDS, opioids, GTN spray, CCBs, recreational drugs
FHx - migraine
SHx - alcohol, smoking, mood, employment
Precipitating factors/major events?
Establish course of symptoms
Loss of interest, appetite, tiredness, poor concentration, self esteem, guilt, pessimism
Mania, anxiety, delusions, hallucinations, self harm
Alcohol or narcotic use
Triggers (stressors and events)
Delusions - Content, belief, thought interference
Hallucinations - Type (auditory, visual) and what happens
Violence - Risk to self and others
Assess insight into problems and if willing to be helped
SHx - recreational drugs, alcohol, social support, coping
How (especially type and quantity of drug, including alcohol)
Was it planned? (Alone, steps to avoid discovery, 'final acts'
Did they want to die?
Do they regret being alive? How did they feel when help arrived/woke up in hospital?
Still feeling suicidal?
Ask about mood
Hx of psychiatric disorder (previous attempts, self harm, psychosis, traumatic past)
Amount, type, place, time
Features - compulsion, patterns, tolerance, withdrawal, reinstatement after abstinence
History of depression
Describe complications of alcohol abuse
FHx of alcohol/substance abuse
DHx of prescribed and illicit medication
Main symptoms, duration and severity
Weight loss, tremor, vision change, sweating, heat intolerance, palpitations, menses change, diarrhoea
Mental state, anxiety, loss of libido, irritability
Ask about neck swelling
Urination, hunger, thirst - quantify change and severity
Xerostomia, weakness, fatigue, blurred cision, slow healing wounds
Type of diabetes and monitoring
History of diabetes
Use of insulin, oral hypoglycaemics
Alcohol, smoking, diet, exercise, weight, cholesterol
Mini mental state
: Year, season, month, day, date + country, city, district, hospital, floor
: Name three objects, ask patient to repeat until all three in under 1 sec each
: Serial subtraction of 7 from 100, stop after 5 answers. Or spell "world" backwards
: ask for three objects
: Name two objects indicated
: No ifs, ands or buts
: Three stage command - paper in right hand, fold in half, put on floor
: Read and obey "close your eyes"
: Write a sentence
: Copy two intersecting pentagons