General Guide to NAC OSCE History Taking
A candidate gets 2 minutes outside the station to read the clinical case scenario on the door before entering. It is essential to get yourself organized in these 2 minutes. To make the most of your time during the clinical exam, it's important to follow the instructions carefully and take note of any important information. Before you begin the physical examination, use the provided pencil and booklet to record the patient's name, age, sex, and chief complaint. This will help you stay organized and focused throughout the exam.
- Wash hands / use alcohol scrub.
- Introduce yourself.
- Ask for the Patient's name and what would they like to be called, date of birth.
- Explain what you will be doing, history/examination, and obtain consent.
- History Taking:
Good evening Mr ..., I am Dr ..., I am the physician on duty now, and I understand that you are here today because of... In the next few minutes, I will ask you some questions about your cc, to figure out a working plan that can help you. If you have any concerns or questions, please feel free to stop me and let me know.
- Physical examination:
Good evening Mr ..., I am Dr ...; I am the physician in charge now. I understand that you are here today because of... In the next few minutes, I will do a physical exam on your (e.g. shoulder), during which I will ask you to do some movements that may cause some discomfort and maybe some pain, if you feel either, please do not hesitate to stop me. And if you have any concerns, please let me know. And I will be telling the findings to the examiner while we proceed.
- Determine the symptoms with which the patient presented to you.
- Start with an open-ended question.
- What do you mean?
- Can you tell me more about this
- Do not interrupt
- Do not duplicate
- Nod your head
History of present illness
Explore each symptom, and gain as much information as you can about the specific complaint.
(I) Data collection: OCDPQRST + AAA
- Onset: How did it start? Sudden? Gradual?. Setting: What were you doing?
- Course: Are the complaints continuous or on and off (intermittent)? Is it the first time? Has it happened before? When? What happened then? What medication? How often do you have your symptoms? Are the symptoms getting better, worse, or the same?
- Duration: Usually given in the station. If not – How long have your symptoms been? Show empathy if the patient has a long-duration of illness.
- Position: Where did it start? Can you point out exactly where it hurts? Progression: Getting better or worse?
- Quality: Tell me what it feels like. Is it sharp/burning/dull/crampy?
- Radiation: Does it travel anywhere?
- Severity: On a scale from 1 to 10, with 1 being the mildest and 10 the worst pain, how bad is it?
- Timing: Is it worse at a particular time of the day?
- Aggravating / Alleviating factors: What makes it worse? What makes it better?
- Associated symptoms: Have you noticed anything that occurs with it? (I) Associated constitutional symptoms like Fever, Shortness of breath, Cough, Nausea, Vomiting, Diarrhoea, Headache, and Fatigue (FSC NVD HF)
- Fluids: Colour, Odour, Contents/Consistency, Amount, Blood? COCAB
(II) Associated symptoms to a particular system (Review of Systems)
- Respiratory: Chest pain, shortness of breath, cough, sputum, wheezing, runny nose, post nasal drip, contact with an ill person, night sweats, questions for pulmonary embolism (leg pain, long travel, surgery, and OCP use in females)
- CVS : chest pain, orthopnea, paroxysmal nocturnal dyspnea, palpitations, tachycardia.
- GIT: pain in the abdomen, stool, bowel movements, vomiting, jaundice, blood in stools, diet, travel.
- Neurology: headache, loss of consciousness, weakness, paresthesias
- Higher Mental Function: orientation, memory, consciousness.
- Motor: weakness of limbs.
- Sensory: tingling sensation.
- Cerebellum: gait, balance.
- Cranial Nerves: speech, swallowing, vision, hearing.
Past medical/surgical history (AMPLE)
Allergy: Do you have any allergies? Are you allergic to any drugs?
Medication: Do you take medicines at present? Over-the-counter drugs? Supplements? Vaccination?
- Diarrhea? Ask about antibiotics
- Asthma? Aspirin / β–blockers (HTN, heart failure, thyroid disease, social phobias)
- Migraine? OCPs? (any birth control pills)
- Bleeding? Aspirin/blood thinners (Warfarin)
- Torticollis? Anti-psychotics?
Past history of diseases /hospitalization: Diabetes/Hypertension/Asthma/Cancer?
LMP for females
Events: Hospitalised? (medical/surgical/trauma) Any surgical procedures?
- Any long-term disease in the family? DM, HTN, heart attack, stroke?
- Does any specific disease run in the family?
Social history (SAD)
- Smoking, how many packs? For how long? Pack years = (No. of cigarettes per day/20) x years smoked.
- Alcohol, amount? For how long?
- Recreational Drugs? (TRAPPED) Treatment history, Route, Addiction/toxicity/amount, Pattern of use, Prior abstinence, Effects of the drug, Duration of use.
- Occupation? What is your living situation like at home? Whom do you live with?
- Sexual History if the patient lives alone: Are you in any relationship? Are you sexually active?
- Complete your history by reviewing what the patient has told you. Repeat back the important points so that the patient can correct you if there are any misunderstandings or errors.
- You should also address what the patient thinks is wrong with them and what they are expecting/hoping for from the consultation. A useful acronym for this is ICE [I]deas, [C]concerns, and [E]xpectations.
- Discuss initial diagnostic impressions.
- Discuss initial management plans and follow-up tests.
- Ask if they have any other questions or concerns.
- Explain the next steps. Always offer something e.g. a leaflet, website, or specialist nurse contact. Book a follow-up appointment.
- Thank the patient.