Do you know what the most common cause of failing stations in medical student OSCEs?
It’s simple, a students histories are not structured!
Often students don’t feel they have to focus on history taking and usually it turns into guess work.
That kind of guessing is like throwing darts blindfolded and hoping you hit the bull’s eye.
Sometimes it works. Usually it doesn’t.
Fortunately, there’s another way…
This guide shows the format all of your OSCE histories need to be in.
The earlier you can understand this structure, the more time you can spend applying this information.
We have also included a brief sample clerking that a person may take in hospital to show you the format.
The key parts of a medical history are:
Presenting Complaint (PC)
This in the patients own words whats brought them in.
For example you often see something like “pneumonia” in medical notes but the patient would actually come in with something like breathlessness or cough.
History of Presenting Complaint (HPC)
Every individual symptom needs to be explored. This will include:
- When it first began
- Did the come on suddenly (acutely) or gradually (insidiously)
- Duration of symptom
- Progression of symptom
- Is the symptom there all the time or intermittently
A common approach is to use SOCRATES or some variation of it:
- Associated symptoms
- Exacerbating / relieving factors
This is to see if there are any other associated symptoms that are related to what the patient has come in with. In your OSCEs this will help to exclude some differentials and are a large part of getting those precious marks.
Here is a brief overview of what you can ask – if a symptom is present, you’d need to ask the above questions.
General – fevers, night sweats, weight loss
Cardiorespiratory – chest pain, shortness of breath, cough, sputum, palpitations, exercise tolerance
Gastrointestinal – change in bowel habit (blood / mucus), abdominal pain, nausea / vomiting, reflex
Neurological – weakness, muscle wasting, memory loss, pain, paresthesia, loss of consciousness
Urological – frequency, volume, urgency, dysuria (pain on urination), haematuria (blood in urine), hesitancy, poor flow
Rheumatological – pain, swelling, stiffness, rashes
Orthopaedic – pain, swelling, stiffness, clicking / locking / giving way, weight baring
There are more system reviews but these are the main ones you’ll need to get started.
Past Medical History (PMH)
We all have a different way of asking this. Some people say things like “have you been diagnosed with anything in the past”, “have you have had treatment for any conditions” or “do you see your GP regularly about any conditions”
For each condition you should write down: date or time of treatment for example: Appendectomy 2011
You should specifically ask about related conditions. These will definitely feature in your mark scheme, most actors are trained to withhold information until promoted.
For example: if you suspect a myocardial infarction (heart attack) it would be a good idea to ask about hypertension (high blood pressure), diabetes (type 1 or 2), high cholesterol etc.
Drug History (DH)
Ask about regular medications. You will need to ask for the dose and frequency
e.g Paracetamol 1G four times a day
Ask if the patient has any allergies – both medication and food. Ask what happens when they take that
Patient: “I am allergic to amoxicillin”
Doctor: “What happens when you take that?”
Patient: “I come out in a rash all over my body”
Social History (SH)
Smoking – how many a day, for how long?
Alcohol – get the patient to say how much they have in a typical week (then you can work out the units)
Occupation – current or retired. This is more important to some histories such as respiratory (for example exposure to asbestos)
Living arrangement – “who is about home with you”, sometimes it is important to ask about carers, how they do the shopping ect
Family History (FH)
People usually say something like “are there any conditions that run in your family that you are aware of”
In your OSCEs the actors are usually told to be vague, so it is important to ask direct conditions. For example: “has anyone in your family previously had a heart attack”
Ideas, Concerns, Expectations, Feelings
This usually carries some marks in your OSCEs and is a good way to uncover any hidden agendas or points missed in your OSCEs. It is a great way to show the patient (and the examiner) your empathy skills. As a general rule if the actor mentions something twice, it’s probably because they are trying to give you a hint so you can get more marks. This is particularly common in this area of the history.
Generalised swelling of abdomen and legs
Seen oncologist this morning, advised to attend A&E for assessment
Attended A&E due to swelling in legs and abdomen, worse over past 3 months
Previously seen a cardiologist 4 years ago.
Exercise tolerance a couple of steps, worse over the past 3 months
No: chest pain, palpitations, weight loss
Congestive cardiac failure
Lives at home with son
Uses wheelchair to mobilise, zimmer-frame 5 steps
No conditions run in the family that the patient is aware of