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Table of Contents
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Respiratory history taking is an important skill that is often assessed in the OSCE setting. It’s important to
have a systematic approach to ensure you don’t miss any key information. The guide below provides a
framework to take a thorough respiratory history. Check out the respiratory history mark schemehere.
HPC
PAST MEDICAL HX
DRUG HX
FAMILY HX
SOCIAL HX
SYSTEMIC ENQUIRY
INTERACTIVE MARK SCHEME
MARK SCHEME (PDF)
Introduction
Introduce yourself – name/role
1
Confirm patient details – name/DOB
Gain consent
Presenting complaint
It’s important to use open questioning to elicit the patient’s presenting complaint.
Allow the patient time to answer, trying not to interrupt or direct the conversation.
“Ok, so tell me more about that” “Can you explain what that pain was like?”
Severity – e.g. if the symptom is shortness of breath – are they able to talk in full sentences?
Intermittent or continuous? – Is the symptom always present or does it come and go?
Precipitating factors – are there any obvious triggers for the symptom?
Relieving factors – does anything appear to improve the symptoms e.g. an inhaler
Associated features – are there other symptoms that appear associated e.g. fever/malaise
2
Key respiratory symptoms:
Pain – if pain is a symptom, clarify the details of the pain using SOCRATES
Concerns – explore any worries the patient may have regarding their symptoms
Expectations – gain an understanding of what the patient is hoping to achieve from the consultation
Summarising
Summarise what the patient has told you about their presenting complaint.
This allows you to check your understanding regarding everything the patient has told you.
It also allows the patient to correct any inaccurate information and expand further on certain aspects.
Once you have summarised, ask the patient if there’s anything else that you’ve overlooked.
3
Continue to periodically summarise as you move through the rest of the history.
Signposting
Signposting involves explaining to the patient:
What you have covered – “Ok, so we’ve talked about your symptoms and your concerns regarding them”
What you plan to cover next – “Now I’d like to discuss your past medical history and your medications”
Surgical history
Drug history
Regular medications – often provide useful clues as to patients past medical history
Diuretics
Antibiotics
Home oxygen?
4
Beta-Blockers / NSAIDS – bronchoconstriction
ACE inhibitors – dry cough
Cytotoxic agents – interstitial lung disease
Oestrogen – e.g. contraceptive pill / HRT – increased risk of PE
Amiodarone / Methotrexate – pleural effusions / interstitial lung disease
Family history
Respiratory disease? – asthma / atopy / lung cancer / cystic fibrosis
Recent contact with others who were unwell? – viral infections / pneumonia / TB
Social history
Smoking – How many cigarettes a day? How long have they smoked for?
Alcohol – How many units a week? – be specific about type / volume / strength of alcohol
Living situation:
5
Occupation:
Travel history
High-risk areas for tuberculosis (TB)?
Systemic enquiry
Systemic enquiry involves performing a brief screen for symptoms in other body systems.
This may pick up on symptoms the patient failed to mention in the presenting complaint.
Some of these symptoms may be relevant to the diagnosis (e.g. calf pain in pulmonary embolism).
Choosing which symptoms to ask about depends on the presenting complaint and your level of experience.
GI – Appetite / Nausea / Vomiting / Indigestion / Dysphagia / Weight loss / Abdominal pain / Bowel habit
6
Musculoskeletal – Bone and joint pain / Muscular pain
7
GASTROINTESTINAL HISTORY TAKING
8
Posted by Dr Lewis Potter | History taking
Table of Contents
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Gastrointestinal history taking requires a systematic approach to ensure you don’t miss anything
important. This guide structures the history in parallel with the structure of the GI system, beginning at the
mouth and working downwards. Over time you will stop using this approach and only ask a smaller more
focused subset of these questions which are relevant to the given presenting complaint, but it takes time to
become competent at this, so this is a good starting point. Check out the gastrointestinal OSCE mark
scheme here.
HPC
PAST MEDICAL HX
DRUG HX
FAMILY HX
SOCIAL HX
SYSTEMIC ENQUIRY
INTERACTIVE MARK SCHEME
MARK SCHEME (PDF)
9
Opening the consultation
Introduce yourself – name / role
Gain consent
Presenting complaint
It’s important to use open questioning to elicit the patient’s presenting complaint
Allow the patient time to answer, trying not to interrupt or direct the conversation.
“Ok, so tell me more about that” ”Can you explain what that pain was like?”
Onset – when did the symptom start? / was the onset acute or gradual?
Intermittent or continuous? – is the symptom always present or does it come and go?
Precipitating factors – are there any obvious triggers for the symptom?
Relieving factors – does anything appear to improve the symptoms e.g. increasing dietary intake
10
Associated features – are there other symptoms that appear associated (e.g. fever/malaise)
Gastroesophageal reflux
Progressive dysphagia (difficulty swallowing solids at first, then eventually difficulty with liquids) suggests the
presence of a malignant stricture. Especially in elderly patients with associated weight loss and iron deficiency
anaemia.
Haematemesis
Colour:
11
Fresh red blood – undigested – acute bleed – Mallory Weiss tear / oesophageal variceal rupture
Coffee ground – digested – bleeding peptic/ duodenal ulcer
Preceded by forceful retching? – Mallory Weiss tear
Anorexia/weight loss
How much weight over how long? – always suspect malignancy – especially in the elderly
Decreased appetite – may suggest malignancy, or in younger patients possibly anorexia nervosa
Abdominal pain
Is pain localised to a specific area of the abdomen?
Bloating
Common causes of abdominal distension:
Fat – obesity
Flatus – paralytic ileus/obstruction
Faeces – constipation
Fluid – ascites
Fetus – pregnancy
Blood – Fresh red blood (anal fissure/haemorrhoids/IBD). Melaena (upper gastrointestinal bleed)
Urgency– IBD/IBS/gastroenteritis
Laxative use?
Constipation
Duration of constipation
Fresh red blood – anal fissure / haemorrhoids / IBD / polyp / lower GI malignancy
Jaundice
Yellowing of the skin and sclera
Dark urine
Causes of jaundice:
13
Pain
If pain is a symptom, clarify the details of the pain using SOCRATES
Concerns – explore any worries the patient may have regarding their symptoms
Expectations – gain an understanding of what the patient is hoping to achieve from the consultation
Summarising
Summarise what the patient has told you about their presenting complaint.
This allows you to check your understanding regarding everything the patient has told you.
It also allows the patient to correct any inaccurate information and expand further on certain aspects.
Once you have summarised, ask the patient if there’s anything else that you’ve overlooked.
Continue to periodically summarise as you move through the rest of the history.
Signposting
Signposting involves explaining to the patient:
What you have covered – “Ok, so we’ve talked about your symptoms”
What you plan to cover next – “Now I’d like to discuss your past medical history”
Travel history
Local food? – e.g. salmonella poisoning
Drug history
Gastrointestinal medications:
Laxatives
Loperamide
H2 receptor antagonists
ALLERGIES?
15
Family history
Gastrointestinal disease – malignancy / IBD / GORD
Social history
Smoking – How many cigarettes a day? How many years have they smoked for?
Alcohol – How many units a week? – be specific about type / volume / strength of alcohol
Diet:
Living situation:
Occupation
16
Systemic enquiry
Systemic enquiry involves performing a brief screen for symptoms in other body systems.
This may pick up on symptoms the patient failed to mention in the presenting complaint.
Some of these symptoms may be relevant to the diagnosis (e.g. erythema nodosum in inflammatory bowel
disease).
Choosing which symptoms to ask about depends on the presenting complaint and your level of experience.
GI – Appetite / Nausea / Vomiting / Indigestion / Dysphagia / Weight loss / Abdominal pain / Bowel habit
17
CHEST PAIN HISTORY
Posted by Dr Lewis Potter | History taking
Table of Contents
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Taking a comprehensive chest pain history is an important skill that is often assessed in the OSCE setting.
It’s important to have a systematic approach to ensure you don’t miss any key information. The guide below
provides a framework to take a thorough chest pain history. Check out the chest pain history OSCE mark
scheme here.
HPC
PAST MEDICAL HX
DRUG HX
FAMILY HX
SOCIAL HX
SYSTEMIC ENQUIRY
INTERACTIVE MARK SCHEME
MARK SCHEME (PDF)
Gain consent
Presenting complaint
It’s important to use open questioning to elicit the patient’s presenting complaint
Allow the patient time to answer, trying not to interrupt or direct the conversation.
“Ok, so tell me more about that” “Can you explain what that chest pain was like?”
Onset:
19
What was the patient doing at the time of onset? (exertional / at rest)
Character:
Radiation:
Associated symptoms:
Time course:
Exacerbating/relieving factors:
Concerns – explore any worries the patient may have regarding their symptoms
Expectations – gain an understanding of what the patient is hoping to achieve from the consultation
Summarising
Summarise what the patient has told you about their presenting complaint.
This allows you to check your understanding regarding everything the patient has told you.
It also allows the patient to correct any inaccurate information and expand further on certain aspects.
Once you have summarised, ask the patient if there’s anything else that you’ve overlooked.
Continue to periodically summarise as you move through the rest of the history.
Signposting
Signposting involves explaining to the patient:
What you have covered – “Ok, so we’ve talked about your symptoms and your concerns regarding them”
What you plan to cover next – “Now I’d like to discuss your past medical history and your medications”
21
Past medical history
Cardiovascular disease:
Angina
Hyperlipidaemia
Respiratory disease:
Pneumonia
Pneumothorax
Pulmonary embolus
Gastrointestinal disease:
Gastro-oesophageal reflux
Oesophageal spasm
Drug history
Regular prescribed medication
22
Antiplatelets or anticoagulants
GTN spray
Herbal remedies
Family history
Cardiovascular disease at a young age – myocardial infarction / hypertension / thrombophilia
Are parents still in good health? – if deceased sensitively determine age and cause of death
Social history
Smoking – How many cigarettes a day? How many years have they smoked for?
Living situation:
23
Activities of daily living:
Systemic enquiry
Systemic enquiry involves performing a brief screen for symptoms in other body systems.
This may pick up on symptoms the patient failed to mention in the presenting complaint.
Some of these symptoms may be relevant to the diagnosis (e.g. fever in pericarditis).
Choosing which symptoms to ask about depends on the presenting complaint and your level of experience.
GI – Appetite / Nausea / Vomiting / Indigestion / Dysphagia / Weight loss / Abdominal pain / Bowel habit
Summarise history
Cardiovascular
Acute coronary syndrome:
Symptoms are often worsened by exertion and improved with GTN spray
Stable angina:
Pericarditis:
25
Patient may have had multiple episodes in the past
Aortic dissection:
“Tearing” in nature
Respiratory
Pneumonia:
Spontaneous pneumothorax:
Pleuritic in nature
Shortness of breath
Pulmonary embolism:
Shortness of breath
Haemoptysis (rare)
Gastrointestinal
Gastro-oesophageal reflux:
26
Burning in nature
Oesophageal spasm:
27
UROLOGICAL HISTORY TAKING
Posted by Dr Lewis Potter | History taking
Table of Contents
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Urological history taking is an important skill that is often assessed in the OSCE setting. It’s important to
have a systematic approach to ensure you don’t miss any key information. The guide below provides a
framework to take a thorough urological history. Check out the urological history taking mark scheme here.
HPC
PAST MEDICAL HX
DRUG HX
FAMILY HX
SOCIAL HX
SYSTEMIC ENQUIRY
INTERACTIVE MARK SCHEME
MARK SCHEME (PDF)
Gain consent
Presenting complaint
It’s important to use open questioning to elicit the patient’s presenting complaint
Allow the patient time to answer, trying not to interrupt or direct the conversation.
“Ok, so tell me more about that” “Can you explain what that pain was like?”
29
Dysuria
Frequency
Urgency
Nocturia
Haematuria
Hesitancy and terminal dribbling
Poor urinary stream
Incontinence
Fever/rigors – suggestive of infection/urosepsis
Nausea/vomiting – often associated with pyelonephritis
Onset – When did the symptom start? / Was the onset acute or gradual?
Severity – i.e. If the symptom was frequency – how many times a day?
Intermittent or continuous? – Is the symptom always present or does it come and go?
Precipitating factors – Are there any obvious triggers for the symptom?
Concerns – explore any worries the patient may have regarding their symptoms
Expectations – gain an understanding of what the patient is hoping to achieve from the consultation
Summarising
Summarise what the patient has told you about their presenting complaint.
This allows you to check your understanding regarding everything the patient has told you.
30
It also allows the patient to correct any inaccurate information and expand further on certain aspects.
Once you have summarised, ask the patient if there’s anything else that you’ve overlooked.
Continue to periodically summarise as you move through the rest of the history.
Signposting
Signposting involves explaining to the patient:
What you have covered – “Ok, so we’ve talked about your symptoms and your concerns regarding them”
What you plan to cover next – “Now I’d like to discuss your past medical history and your medications”
Drug history
Relevant prescribed medication:
31
Other regular medications
Herbal remedies
Family history
Urological disease – increased risk of renal stones if parents previously affected
Are parents still in good health? – if deceased sensitively determine age and cause of death
Social history
Smoking – How many cigarettes a day? How many years have they smoked for?
Living situation:
32
Occupation – increased risk of bladder cancer in those working in specific industries – industrial
dyes/textiles/rubber/plastics/leather tanning
Systemic enquiry
Systemic enquiry involves performing a brief screen for symptoms in other body systems.
This may pick up on symptoms the patient failed to mention in the presenting complaint.
Some of these symptoms may be relevant to the diagnosis (e.g. back pain with renal stones).
Choosing which symptoms to ask about depends on the presenting complaint and your level of experience.
GI – Appetite / Nausea / Vomiting / Indigestion / Dysphagia / Weight loss / Abdominal pain / Bowel habit
33
DERMATOLOGICAL HISTORY TAKING – OSCE GUIDE
Posted by Jacob Michie | Dermatology, History taking
Table of Contents
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Taking a dermatological history is an important skill that is often assessed in the OSCE setting. It usually
involves taking a history of a skin lesion or rash, and it’s important to have a systematic approach to ensure
you don’t miss any key information. The guide below provides a framework to take a thorough history of
any skin problem. Check out the dermatology history taking OSCE mark scheme here.
HPC
PAST MEDICAL HX
DRUG HX
FAMILY HX
SOCIAL HX
SYSTEMIC ENQUIRY
INTERACTIVE MARK SCHEME
MARK SCHEME (PDF)
Introduction
Introduce yourself – name/role
34
Explain the need to take a history
Gain consent
Presenting complaint
It’s important to use open questioning to elicit the patient’s presenting complaint
Allow the patient time to answer, trying not to interrupt or direct the conversation
“Ok, so tell me more about the rash” “Can you explain what that pain was like?”
Intermittent or continuous – is the skin problem always present or does it come and go?
Location/distribution:
35
Number of lesions?
Is it spreading?
Precipitating factors – are there any obvious triggers for the symptom?
Relieving factors – does anything appear to improve the symptoms (e.g. steroid cream)?
Associated features – are there other symptoms that appear associated (e.g. fever/malaise)?
When?
Prescribed medication
Contact history – has the patient been in contact with an infectious skin problem (e.g. chickenpox)?
Ask the patient about how their skin reacts to sun exposure to help determine their skin type (Fitzpatrick
scale)
Pain
If pain is a symptom, clarify the details of the pain using SOCRATES
Concerns – explore any worries the patient may have regarding their symptoms
Expectations – gain an understanding of what the patient is hoping to achieve from the consultation
Summarising
Summarise what the patient has told you about their presenting complaint.
This allows you to check your understanding regarding everything the patient has told you.
It also allows the patient to correct any inaccurate information and expand further on certain aspects.
Once you have summarised, ask the patient if there’s anything else that you’ve overlooked.
Continue to periodically summarise as you move through the rest of the history.
Signposting
Signposting involves explaining to the patient:
What you have covered – “Ok, so we’ve talked about your symptoms and your concerns regarding them”
What you plan to cover next – “Now I’d like to discuss your past medical history and your medications”
37
Past medical history
Skin disease:
Skin cancer
Drug history
Skin treatments – creams / ointments / UV therapy / antibiotics / biologics
Regular medication – including length of treatment (paying particular attention to those started around
the time of the skin problem)
Antibiotics
Cosmetics
Herbal remedies
38
Family history
Skin conditions – e.g. psoriasis / hereditary hemorrhagic telangiectasia
Skin cancer
Social history
Occupation:
Do the skin problems improve when the patient is off from work?
Smoking – How many cigarettes a day? How many years have they smoked for?
Living situation:
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Travel history
Where did the patient travel to?
Sun exposure – was the skin problem worsened by sun exposure? (e.g. facial rash in lupus)
Systemic enquiry
Systemic enquiry involves performing a brief screen for symptoms in other body systems.
This may pick up on symptoms the patient failed to mention in the presenting complaint.
Some of these symptoms may be relevant to the diagnosis (e.g. arthralgia in psoriatic arthritis).
Choosing which symptoms to ask about depends on the presenting complaint and your level of experience.
GI – Appetite / Nausea / Vomiting / Indigestion / Dysphagia / Weight loss / Abdominal pain / Bowel habit
40
GYNAECOLOGICAL HISTORY TAKING
Posted by Dr Lewis Potter | History taking
Table of Contents
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A gynaecological history involves asking questions relevant to the femalereproductive system. Some of
the questions are highly personal and therefore good communication skills and a respectful manner are
absolutely essential.
Taking a gynaecological history requires asking a lot of questions that are not part of the “standard” history
taking format and therefore it’s important to understand what information you are expected to gain.
Presenting complaint
It’s important to use open questioning to elicit the patient’s presenting complaint:
Allow the patient time to answer, trying not to interrupt or direct the conversation
Onset:
42
When did the symptom start?
Duration:
How long did the symptom last? (e.g. minutes, hours, days, weeks, months, years)
Severity:
Course:
Cyclical:
Intermittent or continuous:
Precipitating factors:
Relieving factors:
43
Associated features:
Previous episodes:
Site:
Onset:
Character:
Radiation:
Does the pain radiate anywhere? (e.g. shoulder tip pain can occur in ectopic pregnancy)
Associations:
Time course:
What is the overall time course of the pain? (e.g. worsening, improving, fluctuating)
Severity:
On a scale of 0-10, how severe is the pain, if 0 is no pain and 10 is the worst pain you’ve ever experienced?
Gynaecological symptoms
Once you have completed exploring the history of presenting complaint, you need to move on to
more focused questioning relating to the common symptoms of gynaecological disease.
We have included a focused list of the key symptoms to ask about when taking a gynaecological history,
followed by some background information on each, should you want to know a little more.
Vaginal bleeding
Abnormal vaginal bleeding is an important symptom that can be relevant to a wide range of
gynaecological disease.
Post-coital bleeding
Causes include cervical ectropion, infection (including STIs), vaginitis, malignancy (e.g. cervical cancer)
Intermenstrual bleeding
45
Vaginal bleeding occurring between menstrual periods
Causes include infection (including STIs), malignancy (e.g. cervical or endometrial cancer), uterine fibroids,
endometriosis, hormonal contraception (e.g. Mirena coil) and pregnancy
Post-menopausal bleeding
Vaginal bleeding that occurs after the menopause (when there should be no further menstrual periods)
Causes include malignancy (e.g. cervical or endometrial cancer), hormonal replacement therapy and vaginal
atrophy
Vaginal discharge
All healthy women will have some degree of regular vaginal discharge, so it is important to distinguish
between normal and abnormal vaginaldischarge when taking a gynaecological history.
You should ask if the patient has noticed any changes to the following characteristics of
their vaginal discharge:
Volume
Dyspareunia
Dyspareunia refers to pain that occurs during sexual intercourse. It has several causes including
infections, endometriosis, vaginal atrophy, malignancy and bladder inflammation.
46
Duration of the symptom
Infections such as candida (thrush), bacterial vaginosis and sexually transmitted infections
Vaginal atrophy occurs in post-menopausal women and can lead to itching and bleeding of the vagina
Lichen sclerosis appears as white patches on the vulva and is associated with itching
Concerns:
47
Explore any worries the patient may have regarding their symptoms
Expectations:
Gain an understanding of what the patient is hoping to achieve from the consultation
What were you hoping you’d get out of our consultation today?
Summarising
Summarise what the patient has told you about their presenting complaint.
This allows you to check your understanding regarding everything the patient has told you so far.
It also provides an opportunity for the patient to correct any inaccurate information and expand further
on relevant aspects of the history.
Once you have summarised, ask the patient if there’s anything else that you’ve overlooked.
Continue to periodically summarise as you move through the rest of the history.
Signposting
Signposting involves explaining to the patient:
What you have covered so far: “Ok, so we’ve talked about your symptoms.”
What you plan to cover next: “Now I’d like to discuss your past medical history.”
Menstrual history
A menstrual history involves clarifying the details of a woman’s menstrual cycle. It is an essential part of any
gynaecological history and it, therefore, it should not be missed.
48
Average duration is 5 days
Frequency:
Heavy menstrual blood loss is defined as more than 80mls (16 teaspoons) or having periods that last longer
than 7 days
The definition of what is a “heavy period” compared to a “normal period” is highly subjective and therefore
you should ask the woman how the current periods compare to her usual loss. If the volume of bleeding is
impacting on the woman’s day to day life, it is significant.
“Have you been passing blood clots larger than a 10p coin?”
It is common for women to experience abdominal and pelvic pain when menstruating.
Menstrual pain can sometimes be severe and have a significant impact on a woman’s day to day quality of
life.
Use the SOCRATES acronym shown above to further assess menstrual pain.
49
Date of last menstrual period (LMP):
If late, consider performing a pregnancy test, particularly in the context of abdominal pain (to rule out
ectopic pregnancy).
Age at menarche:
Early menarche is associated with an increased risk of breast cancer and cardiovascular disease
Age at menopause
Ask about menopausal symptoms such as hot flushes and vaginal dryness
Contraception
Clarify the type of contraception currently used:
Barrier methods
It is useful to be aware of what the patient has previously tried, particularly if considering a change to their
current choice of contraception.
50
Reproductive plans
You should ask the patient if they are considering having children in the future (or are currently
trying to fall pregnant).
This is important to know when considering treatments for their gynaecological issue (e.g. you wouldn’t
suggest endometrial ablation or hysterectomy for menorrhagia if the patient was planning for a future
pregnancy).
Cervical screening
Confirm the date of the last cervical screening test
Ask if the patient received any treatment if the cervical screening test was abnormal and check if follow up
is in place
Ectopic pregnancy
Endometriosis
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Bartholin’s cyst
Cervical ectropion
Migraine with aura – oestrogen containing medications (e.g. combined oral contraceptive) would be
contraindicated
Previous venous thromboembolism (VTE) – oestrogen containing medications would be contraindicated
Breast cancer (current or previous) – use of oestrogen containing medications would be usually be
contraindicated or require specialist input before being commenced
Bleeding disorders (e.g. Von Willebrand’s) would be relevant if a patient presented with heavy vaginal
bleeding
Caesarian section
Hysterectomy
52
Obstetric history
It is important to take a brief obstetric history as part of a gynaecological assessment, as it may be
relevant. This is less detailed than a focused obstetric history.
You need to ask questions in a sensitive manner, as discussing previous miscarriages and terminations can
be very difficult for the patient.
Basic details
Gravidity: The number of times a woman has been pregnant, regardless of the outcome.
Parity:
Previous pregnancies
Age of children
Birth weight
Mode of delivery
If relevant, ask if the patient is currently breast feeding, as this is a contraindication to some types of
contraceptives (e.g. combined oral contraceptive)
53
Drug history
Hormonal replacement therapy (HRT)
Duration of use
Other
Recent antibiotics (increased the risk of vaginal thrush)
Liver enzyme-inducing drugs (e.g. Rifampicin) can be a contraindication to commencing patients on the
combined oral contraceptive pill
Other regular medication
Over the counter medication (e.g. St John’s Wart can interfere with the metabolism of the COCP)
Drug allergies
Family history
Important conditions to consider that may be relevant to a gynaecological presentation:
Ovarian, endometrial and breast cancer – possible familial inheritance (e.g. BRCA gene)
Bleeding disorders – menorrhagia can sometimes be the first presentation of an inherited bleeding
disorder (e.g. Von Willebrand disease)
Venous thromboembolism (VTE) – patients who have a significant family history of VTE in a first-degree
relative (particularly if they were less than 45 when it developed) may be at increased risk of VTE and
therefore medications such as combined oral contraceptives, would often be contraindicated
Social history
54
Understanding the social context of a patient is absolutely key to building a complete picture of their health.
Social factors have a significant influence on a patient’s overall health and it’s therefore key that a
comprehensive social history is obtained.
Smoking:
If smoking more than 40 a day, the combined oral contraceptive would be contraindicated
If a women over 35 years old is smoking more than 15 cigarettes a day, this would also be a
contraindication to the combined oral contraceptive
Weight:
Obesity is associated with polycystic ovarian syndrome and carries a greater risk of endometrial cancer
A raised BMI may be a contraindication to some treatments, including combined oral contraceptives
Home situation:
How is the disease impacting on their ability to carry out activities of daily living?
All of these factors are important when planning management of the patient’s health problem.
Occupation:
This may pick up on symptoms the patient failed to mention in the presenting complaint.
Some of these symptoms may be relevant to the diagnosis (e.g. painful defecation secondary to
endometriosis).
Choosing which symptoms to ask about depends on the presenting complaint, however, a selection of
potentially relevant systemic symptoms to a gynaecological presentation are shown below.
Fever:
Weight loss:
Malignancy
Respiratory:
Gastrointestinal:
Urinary:
Musculoskeletal:
Dermatology:
56
White patches on the vulva/vagina associated with pruritis (lichen sclerosis)
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Back pain is a common presenting complaint associated with a wide range of acute and chronic medical
conditions. These can vary in severity from minor complaints such as muscular strain to life-threatening
conditions such as a dissecting aortic aneurysm. It is important that a thorough history is obtained to
identify any red flags indicating that a patient requires further diagnostic investigations. Check out the back
pain history taking mark scheme here.
HPC
PAST MEDICAL HX
DRUG HX
FAMILY HX
SOCIAL HX
SYSTEMIC ENQUIRY
INTERACTIVE MARK SCHEME
MARK SCHEME (PDF)
Gain consent
Presenting complaint
It’s important to use open questioning to elicit the patient’s presenting complaint “So what’s brought
you in today?” or “Tell me about your symptoms”
Allow the patient time to answer, trying not to interrupt or direct the conversation.
Facilitate the patient to expand on their presenting complaint if required. “Ok, so tell me more about
that” “Can you explain what that back pain is like?”
Onset:
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When did the pain first start?
What was the patient doing at the time of onset? – fracture and muscular related pain often has a sudden
onset associated with some form of trauma (fall/heavy lifting/sudden twisting motion)
Character:
Is the pain constant (e.g. spinal fracture/inflammatory arthritis) or intermittent (e.g. muscular spasm)?
Is the pain present at rest? / Does the pain wake the patient at night? – consider inflammatory causes (e.g.
rheumatoid arthritis/ankylosing spondylitis) and malignancy (e.g. metastatic deposits)
Has the patient suffered pain like this before? / What was felt to be the cause? / How was it managed?
Pain described as “burning” in nature is typically neuropathic in origin (e.g. nerve root compression)
Sharp pain is less specific but is associated with acute spinal fracture, muscular spasm and pulmonary
embolism (pleuritic)
Associated symptoms:
Sensory disturbances – radiculopathy / cauda equina syndrome (e.g. saddle paresthesia) / spinal cord
compression
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Motor disturbances (weakness) – cord compression (displaced fracture/prolapsed
intervertebral disc/epidural abscess/haematoma)
Urinary retention – cauda equina syndrome / spinal cord compression / severe back pain
Urinary incontinence – cauda equina syndrome / spinal cord compression
Other urinary symptoms (e.g. dysuria, increased frequency, haematuria) – urinary tract infections /
pyelonephritis
Fever/chills – pyelonephritis / pneumonia / vertebral discitis
Nausea and vomiting – pyelonephritis / renal colic / myocardial infarction
Fatigue/malaise – pyelonephritis / inflammatory arthritis / malignancy
Weight loss – malignancy
Haematemesis or melaena – peptic ulcer / duodenal ulcer / gastrointestinal malignancy
Early morning stiffness – ankylosing spondylitis / rheumatoid arthritis
Diaphoresis/dyspnoea – myocardial infarction
Muscular spasms – can occur alongside fracture/trauma
Time course:
Exacerbating/relieving factors:
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Red flags for back pain (history only) ¹
Cauda equina syndrome:
Severe or progressive bilateral neurological deficit of the legs, such as major motor weakness with knee
extension, ankle eversion, or foot dorsiflexion
Spinal fracture:
Sudden onset of severe central spinal pain which is relieved by lying down
There may be a history of major trauma (such as a road traffic collision or fall from a height), minor trauma,
or even just strenuous lifting in people with osteoporosis or those who use corticosteroids
Cancer:
Aged 50 or older
Severe unremitting pain that remains when the person is supine, aching night pain that prevents or disturbs
sleep, pain aggravated by straining (e.g. opening bowels, coughing or sneezing), and thoracic pain
No symptomatic improvement after four to six weeks of conservative lower back pain therapy
Past history of cancer — breast, lung, gastrointestinal, prostate, renal, and thyroid cancers are more likely to
metastasise to the spine
Fever
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Diabetes
Concerns – explore any worries the patient may have regarding their symptoms
Expectations – gain an understanding of what the patient is hoping to achieve from the consultation
Summarising
Summarise what the patient has told you about their presenting complaint. This allows you to check
your understanding regarding everything the patient has told you.
It also allows the patient to correct any inaccurate information and expand further on certain aspects.
Once you have summarised, ask the patient if there’s anything else that you’ve overlooked. Continue
to periodically summarise as you move through the rest of the history.
Signposting
Signposting involves explaining to the patient:
What you have covered – “Ok, so we’ve talked about your symptoms and your concerns regarding them”
What you plan to cover next –“Now I’d like to discuss your past medical history and your medications”
When?
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Was a diagnosis made?
Previous treatment for back pain (e.g. physiotherapy, analgesia, steroid injections)
Drug history
Regular medications
Over the counter drugs – important to clarify what analgesics they are purchasing over the counter to
ensure they are not overdosing (e.g. using regular paracetamol in addition to co-codamol)
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Herbal remedies
Family history
Rheumatological disease – rheumatoid arthritis/ankylosing spondylitis
Osteoporosis – fractures
Social history
Smoking – How many cigarettes a day? How many years have they smoked for?
Alcohol – How many units a week? – type/volume/strength of alcohol – history of alcohol abuse is
associated with pancreatitis
Recreational drug use – e.g. intravenous drug use – osteomyelitis / vertebral discitis / epidural abscess
Occupation:
What does the job involve? (e.g. heavy lifting, repetitive movements, sitting for prolonged periods, driving)
Is the patient currently able to do their job?
Is the patient satisfied in their job? (job dissatisfaction is associated with chronic lower back pain,
furthermore, the longer someone is absent from work due to back pain, the less likely they are to return to
work³)
Stress – emotional stress can be associated with musculoskeletal lower back pain
Exercise – baseline level of the patient’s day to day activity (patients participating in contact sports or
weightlifting/strength sports may be at an increased risk of back injuries)
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Living situation:
Systemic enquiry
Systemic enquiry involves performing a brief screen for symptoms in other body systems. This may pick up on
symptoms the patient failed to mention in the presenting complaint. Some of these symptoms may be relevant
to the diagnosis (e.g. weight loss secondary to malignancy). Choosing which symptoms to ask about depends on
the presenting complaint and your level of experience.
GI – Appetite / Nausea / Vomiting / Indigestion / Dysphagia / Weight loss / Abdominal pain / Bowel habit
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HEADACHE HISTORY TAKING
Posted by Jennifer Rodgers | History taking
Table of Contents
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Headache is a common presenting complaint and certainly something you’ll encounter many times over your
career. The vast majority of headaches are not life-threatening, with tension headache and migraine being the
most common diagnoses. Headache is however also associated with a number of serious conditions and
therefore it is essential you are able to take a comprehensive headache history and identify red flags that
indicate the need for further investigation. Check out the headache history taking OSCE mark scheme here.
HPC
PAST MEDICAL HX
DRUG HX
FAMILY HX
SOCIAL HX
SYSTEMIC ENQUIRY
INTERACTIVE MARK SCHEME
MARK SCHEME (PDF)
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Opening the consultation
Introduce yourself – name/role
Gain consent
Presenting complaint
It’s important to use open questioning to elicit the patient’s presenting complaint
Allow the patient time to answer, trying not to interrupt or direct the conversation.
“Ok, so tell me more about that” “Can you explain what that pain was like?”
Onset:
Was the onset acute or gradual? (sudden onset “thunderclap” headache is suggestive
of subarachnoid haemorrhage)
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Character – aching / throbbing / pounding / pulsating / pressure / pins and needles / stabbing
Radiation – neck (meningitis) / face (e.g. trigeminal neuralgia) / eye (e.g. acute closed angle glaucoma)
Associated symptoms:
Timing:
Duration of headache?
Is it episodic?
Diurnal variation?
Chronic headaches – in a month of 30 days, for how many of those days would the patient have a headache?
Exacerbating/relieving factors:
Exacerbating factors – are there any obvious triggers for the symptom? (e.g. caffeine / codeine / stress /
postural change)
Relieving factors – does anything appear to improve the symptoms(e.g. improvement upon lying flat
suggestive of reduced ICP).
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Severity:
Red flags
Red flags within a headache history are many and varied, so familiarise yourself with common
patterns.
A headache of sudden onset, reaching maximum intensity by five minutes (suggestive of subarachnoid
haemorrhage)
Fever with a worsening headache, meningeal irritation and change in mental status (viral/bacterial
meningitis)
New-onset focal neurological deficit, personality change or cognitive dysfunction (intracranial
haemorrhage/ischaemic stroke/space occupying lesion)
Decreased level of consciousness
Headache associated with severe eye pain/blurred vision/nausea/vomiting/red eye (acute angle closure
glaucoma)
Ideas, Concerns and Expectations
Ideas – what are the patient’s thoughts regarding their symptoms?
Concerns – explore any worries the patient may have regarding their symptoms
Expectations – gain an understanding of what the patient is hoping to achieve from the consultation
Summarising
Summarise what the patient has told you about their presenting complaint.
This allows you to check your understanding regarding everything the patient has told you.
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It also allows the patient to correct any inaccurate information and expand further on certain aspects.
Once you have summarised, ask the patient if there’s anything else that you’ve overlooked.
Continue to periodically summarise as you move through the rest of the history.
Signposting
Signposting involves explaining to the patient:
What you have covered – “Ok, so we’ve talked about your symptoms and your concerns regarding them”
What you plan to cover next – “Now I’d like to discuss your past medical history and your medications”
History of malignancy?
Previous surgery? – e.g. CSF shunting (blocked/infected shunts present with headache)
Drug history
Regular prescribed medication?
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In a month with 30 days, on how many days would they use painkillers?
Family history
Neurological diagnoses in first degree relatives? – e.g. migraine
Social history
Smoking – How many cigarettes a day? How long have they smoked for?
Alcohol – How many units a week? – be specific about type / volume / strength of alcohol
Living situation:
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Is the headache interfering significantly with their daily life?
Systemic enquiry
Systemic enquiry involves performing a brief screen for symptoms in other body systems.
This may pick up on symptoms the patient failed to mention in the presenting complaint.
Some of these symptoms may be relevant to the diagnosis (e.g. neck stiffness in meningitis).
Choosing which symptoms to ask about depends on the presenting complaint and your level of experience.
GI – Appetite / Nausea / Vomiting / Indigestion / Dysphagia / Weight loss / Abdominal pain / Bowel habit
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RHEUMATOLOGICAL HISTORY TAKING – OSCE GUIDE
Posted by Merina Kurian | History taking
Table of Contents
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Taking a rheumatological history is an important skill that can be assessed in the OSCE setting. It usually
involves taking a history of a joint problem, with the patient also mentioning other systemic features of
rheumatological disease. It’s important to have a systematic approach to ensure you don’t miss any key
information. The guide below provides a framework to take a thorough history of rheumatological
pathology. Check out the rheumatological history taking mark scheme here.
HPC
PAST MEDICAL HX
DRUG HX
FAMILY HX
SOCIAL HX
SYSTEMIC ENQUIRY
CLOSING THE CONSULTATION
INTERACTIVE MARK SCHEME
MARK SCHEME (PDF)
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Introduction
Introduce yourself – name/role
Gain consent
Presenting complaint
It’s important to use open questioning to elicit the patient’s presenting complaint
Allow the patient time to answer, trying not to interrupt or direct the conversation
Pain
Rashes and skin lesions
Immune
Stiffness
Malignancy
Swelling and Sweats
Pain
If pain is a symptom, clarify the details of the pain using SOCRATES
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Site – where is the pain? (e.g. monoarthritis vs polyarthritis)
Onset – when did it start? / sudden vs gradual? / associated with trauma?
Character – how would you describe the pain? (e.g. sharp/dull ache/burning)
Radiation – does the pain move anywhere else?
Associations – other symptoms associated with the pain? (e.g. stiffness)
Time course – worsening/improving/fluctuating/time of day dependent? (e.g. rheumatoid arthritis worse
in mornings vs osteoarthritis worst during/after activity)
Exacerbating / Relieving factors – does anything make the pain worse or better?
Severity – on a scale of 0-10, how severe is the pain?
Immune
Systemic sclerosis: CREST
Musculoskeletal symptoms (arthralgia, myalgia) – “Do you have any aching in any of your joints or muscles
currently?”
Dermatological symptoms (malar rash/butterfly rash), photosensitivity, discoid lupus) – “Have you noticed
any rashes or skin changes recently?”
Renal (acute nephritic disease) – “Have you noticed any blood or other changes in your urine?”
Neuropsychiatric (seizure, psychosis) – “Have you noticed any changes in your thoughts or mood?”
Pulmonary (pneumonitis, interstitial lung disease) – “Have you felt more short of breath recently?”
Gastrointestinal (nausea, dyspepsia, abdominal pain)
Cardiac (pericarditis, myocarditis) – “Have you experienced any chest pain recently?”
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Haematological (leukopenia, anaemia, thrombocytopenia) – “Have you felt more fatigued or found that you
are bruising more easily recently?”
Sjogren’s syndrome
Dry eyes
Dry mouth
Chronic cough
Stiffness
Reduced range of movement
Malignancy
Ask about B symptoms to rule out malignancy:
Fever
Night sweats
Weight loss
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Septic arthritis (often the causative organism is from another source e.g. urine)
Concerns – explore any worries the patient may have regarding their symptoms
Expectations – gain an understanding of what the patient is hoping to achieve from the consultation
Summarising
Summarise what the patient has told you about their presenting complaint.
This allows you to check your understanding regarding everything the patient has told you.
It also allows the patient to correct any inaccurate information and expand further on certain aspects.
Once you have summarised, ask the patient if there’s anything else that you’ve overlooked.
Continue to periodically summarise as you move through the rest of the history.
Signposting
Signposting involves explaining to the patient:
What you have covered – “Ok, so we’ve talked about your symptoms and your concerns regarding them”
What you plan to cover next – “Now I’d like to discuss your past medical history and your medications”
Autoimmune conditions
ALLERGIES
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Past surgical history
Joint surgery/replacements
Drug history
Analgesics
Immunosuppressants:
Family history
Ask about any history of rheumatological disease in first-degree relatives.
Social history
Occupation:
Smoking – How many cigarettes a day? How many years have they smoked for?
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Recreational drug use – IV drug use is a potential source of joint sepsis
Living situation:
Systemic enquiry
Involves performing a brief screen for symptoms in other body systems.
This may pick up on symptoms the patient failed to mention in the presenting complaint.
Some of these symptoms may be relevant to the diagnosis (e.g. arthralgia in psoriatic arthritis).
Choosing which symptoms to ask about depends on the presenting complaint and your level of experience.
GI – Appetite / Nausea / Vomiting / Indigestion / Dysphagia / Weight loss / Abdominal pain / Bowel habit
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OBSTETRIC HISTORY TAKING
Posted by Dr Lewis Potter | History taking
Table of Contents
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An obstetric history involves asking questions relevant to a patient’s current and previous pregnancies.
Some of the questions are highly personal and therefore good communication skills and a respectful
manner are absolutely essential.
Taking an obstetric history requires asking a lot of questions that are not part of the “standard” history
taking format and therefore it’s important to understand what information you are expected to gain.
It’s also worth noting that before 18 weeks gestation, most obstetric conditions are unlikely and therefore
your history should focus more on the gynaecological aspect (e.g. abdominal pain at 8 weeks gestation could
be an ectopic pregnancy).
Gravidity (G) is the number of times a woman has been pregnant, regardless of the outcome (e.g. G2).
Parity (P) is the total number of pregnancies carried over the threshold of viability (typically 24 + 0 weeks).
G5: The patient’s gravidity is 5 because she has had 5 pregnancies in total, regardless of the outcome.
P4: The patient’s parity would be 4 because she has had 4 pregnancies which were carried beyond 24+0
weeks gestation and a miscarriage lost at 10 weeks gestation.
How does Parity work for twins?
A British Journal of Gynaecology study suggests that a mother who has carried twins to a viable gestational
age should be defined as P1.
However, in clinical practice, only 20% of UK Obstetricians and Midwives follow this definition, with the
remaining 80% referring to twin pregnancy as P2.
As a result, you should be aware that in clinical practice, a mother who has carried twins to a viable
gestational age will often be referred to as P2, but from an academic perspective, they would be deemed as
P1.
Presenting complaint
It’s important to use open questioning to elicit the patient’s presenting complaint:
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“So what’s brought you in today?” or “Tell me about your symptoms”
Allow the patient time to answer, trying not to interrupt or direct the conversation
Onset:
Duration:
How long did the symptom last? (e.g. minutes, hours, days, weeks, months, years)
Severity:
Course:
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Intermittent or continuous:
Precipitating factors:
Relieving factors:
Associated features:
Previous episodes:
Pain
The acronym SOCRATES provides a useful framework for asking about pain (e.g. abdominal pain), as shown
below.
Site:
Onset:
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Character:
Radiation:
Associations:
Time course:
What is the overall time course of the pain? (e.g. worsening, improving, fluctuating)
Severity:
On a scale of 0-10, how severe is the pain, if 0 is no pain and 10 is the worst pain you’ve ever experienced?
Obstetric symptoms
Once you have completed exploring the history of presenting complaint, you need to move on to
more focused questioning relating to the symptoms that may be relevant to pregnancy. We have
included a focused list of the key symptoms to ask about when taking an obstetric history, followed by some
background information on each, should you want to know a little more.
Nausea and vomiting in pregnancy usually begin between the fourth and seventh weeks of gestation,
peaks between the ninth and sixteenth weeks and resolves by around the 20th week of pregnancy.
Persistent vomiting and severe nausea can progress to hyperemesis gravidarum. Hyperemesis
gravidarum refers to persistent and severe vomiting leading to dehydration and electrolyte disturbance,
weight loss and ketonuria. ¹
Reduced fetal movements are associated with adverse pregnancy outcomes, including stillbirth, fetal
growth restriction, placental insufficiency, and congenital malformations. ²
You should therefore always ask about fetal movements one the patient is of the appropriate gestation to be
able to feel them:
Vaginal bleeding
Abnormal vaginal bleeding is an important symptom that can be relevant to a wide range of obstetric and
gynaecological diseases.
It is important to ask about pain, associated trauma (including domestic violence), fever/malaise,
recent ultrasound scan results (e.g. position of the
placenta), cervical screening history, sexual history and pastmedical history to help narrow the
differential diagnosis.
You should also ask about fatigue if anaemia is suspected and symptoms of hypovolaemic shock (e.g. pre-
syncope/syncope) if large blood loss is suspected.
Vaginal discharge
All healthy women will have some degree of regular vaginal discharge, so it is important to distinguish
between normal and abnormal vaginaldischarge when taking an obstetric history.
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You should ask if the patient has noticed any changes to the following characteristics of
their vaginal discharge:
Volume
Urinary symptoms
Urinary tract infections are common in pregnancy and need to be treated promptly. Untreated urinary tract
infections in pregnancy have been associated with increased risk of fetal death, developmental delay and
cerebral palsy.
Fever
Headache/visual changes/swelling
Pre-eclampsia is a relatively common condition in pregnancy which is characterised by maternal
hypertension, proteinuria, oedema, fetal intrauterine growth restriction and premature birth. The condition
can be life-threatening for the mother and the fetus. As a result, it is essential to ask about symptoms of pre-
eclampsia as part of every patient review during pregnancy.
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Other relevant symptoms
Fever is important to ask about when considering infectious pathology (e.g. urinary tract infections,
cervical infections, chorioamnionitis).
Fatigue is a non-specific symptom, but its presence may indicate anaemia or other systemic pathology.
Weight loss is a symptom of hyperemesis gravidarum and other significant conditions (e.g. malignancy,
anorexia nervosa).
Pruritis can occur in obstetric cholestasis.
Concerns:
Explore any worries the patient may have regarding their symptoms
Expectations:
Gain an understanding of what the patient is hoping to achieve from the consultation
What were you hoping you’d get out of our consultation today?
Summarising
Summarise what the patient has told you about their presenting complaint.
This allows you to check your understanding regarding everything the patient has told you so far.
It also provides an opportunity for the patient to correct any inaccurate information and expand further
on relevant aspects of the history.
Once you have summarised, ask the patient if there’s anything else that you’ve overlooked.
Continue to periodically summarise as you move through the rest of the history.
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Signposting
Signposting involves explaining to the patient:
What you have covered so far: “Ok, so we’ve talked about your symptoms.”
What you plan to cover next: “Now I’d like to discuss your past medical history.”
Current pregnancy
Gestation
Clarify the current gestational age of the pregnancy (e.g. 26 weeks and 5 days would be written as
“26+5”).
Accurate estimation of gestation and estimated date of delivery (EDD) is performed using
an ultrasound scan to measure the crown-rump length.
Scan results
Women are offered an ultrasound scan to check for fetal anomalies between 18+0 and 20+6 weeks. You
should ask about the results of the scan (or check the medical records if the patient is unsure). The key
findings you should ask about include:
Growth of the fetus – clarify if it was within normal limits for the current gestation
Placental position – if embedded in the lower third of the uterine cavity there is an increased risk of
placenta praevia
Screening
There are several types of screening that women are offered during pregnancy. You should clarify if the
patient has opted for screening and if so, what the results were.
Immunisation history
Check the patient is currently up to date with their vaccinations:
Flu vaccination
Ask about previous mental health diagnoses and any current thoughts of self-harm and/or suicide if
relevant.
Parity is the total number of pregnancies carried over the threshold of viability (typically 24 + 0 weeks).
Previous pre-term labour increases the risk of pre-term labour in later pregnancies
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Birth weight:
A high birth weight in previous pregnancies raises the possibility of previous gestational diabetes
A low birth weight (small for gestational age) in a previous pregnancy increases the risk of a further small
for gestational age baby
Mode of delivery:
Caesarian section (will have implications for choice of future mode of delivery)
Complications:
Antenatal period – pre-eclampsia, gestational diabetes, gestational hypertension, placenta praevia, shoulder
dystocia
Postnatal period – post-partum haemorrhage, perineal/rectal tears during delivery, retained products of
conception
Assisted reproduction:
Clarify if IVF or other assisted reproductive techniques were used for any previous pregnancies
Stillbirth
As stated below, asking about stillbirths need to be done in a sensitive manner.
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Miscarriage
A miscarriage is the loss of a pregnancy before 24 weeks gestation.
Gestation:
Other details:
Was there any cause identified for the miscarriage? (e.g. genetic syndromes)
Termination of pregnancy
A termination of pregnancy (abortion) is the medical process of ending a pregnancy so it doesn’t result
in the birth of a baby. The pregnancy is ended either by taking medications or having a minor surgical
procedure.
Ectopic pregnancy
An ectopic pregnancy is when a fertilised egg implants itself outside of the uterus, usually in one of the
fallopian tubes.
Ask about the management of the ectopic pregnancy (e.g. expectant, medical, surgical)
Gynaecological history
Cervical screening (known previously as cervical smears):
Endometriosis
Bartholin’s cyst
Cervical ectropion
Examples of medical conditions that are important to be aware of during pregnancy are shown below.
Blood glucose control can deteriorate significantly during pregnancy resulting in poor maternal health and
fetal complications (e.g. macrosomia)
Hypothyroidism:
Epilepsy:
Seizures during pregnancy pose a risk to both the mother and fetus (e.g. miscarriage)
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Pregnancy is a pro-thrombotic state and therefore women who have previously had a venous
thromboembolism are high risk for further VTEs.
They may require prophylactic low molecular weight heparin to reduce their risk.
Blood-borne viruses:
Genetic disease:
Surgical history
Previous surgical procedures such as:
Abdominal or pelvic surgery – can result in adhesions that complicate Caesarian sections
Loop excision of the transitional zone (LETZ) – increased risk of cervical incompetence
Drug history
It is essential to gain an accurate overview of the medications the patient is currently and has previously
taken during the pregnancy. The first trimester is when the fetus is most at risk of teratogenicity from
drugs, as this is when organogenesis occurs.
Regular medications
Clarify the medications the patient has been taking since falling pregnant, noting which they are still taking
and which they have now stopped.
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ACE inhibitors
Sodium valproate
Methotrexate
Retinoids
Trimethoprim
Contraception
Ask if the patient was using contraception prior to falling pregnant and if so, clarify what method of
contraception was being used. Check the patient has stopped their contraception or had their
contraceptive device removed (e.g. coil, implant).
Folic acid (400μg) – recommended daily for the first trimester of pregnancy to reduce the risk of neural
tube defects in the developing fetus
Antiemetics – frequently used in pregnancy to manage nausea and vomiting (e.g. hyperemesis gravidarum)
Aspirin
Herbal remedies
Allergies
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It’s essential to clarify any allergies the patient may have and document these clearly in the notes, including
the type of allergic reaction the patient experienced.
Family history
Taking a brief family history can help to further assess the risk of adverse outcomes to the mother and fetus
during pregnancy. This can also help inform discussions with parents about the risk of their child having a
specific genetic disease (e.g. cystic fibrosis).
Social history
Understanding the social context of a patient is absolutely key to building a complete picture of their health.
Social factors have a significant influence on a patient’s pregnancy and it’s therefore key that a
comprehensive social history is obtained.
Smoking
How many cigarettes a day?
Alcohol
How many units a week?
Recreational drugs
It is important to ask about recreational drug use, as these can potentially have significant consequences on
the mother and developing fetus (e.g. cocaine use increases the risk of placental abruption).
If recreational drug use is identified, patient’s can be offered input from drug cessation services.
Ask about the patient’s current weight – obesity significantly increases the risk of venous
thromboembolism, pre-eclampsia and gestational diabetes during pregnancy
Home situation
Who lives with the patient?
How is the pregnancy impacting on their ability to carry out activities of daily living?
Occupation
Ask about the patient’s current or previous occupation
Domestic abuse
It is important to ask all pregnant women if they are a victim of domestic abuse (in privacy)
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Systemic enquiry
Systemic enquiry involves performing a brief screen for symptoms in other body systems.
This may pick up on symptoms the patient failed to mention in the presenting complaint.
Some of these symptoms may be relevant to the diagnosis (e.g. excessive vomiting in hyperemesis
gravidarum).
Choosing which symptoms to ask about depends on the presenting complaint, however, a selection of
potentially relevant systemic symptoms to an obstetric presentation are shown below.
Fever:
Chorioamnionitis
Weight loss:
Hyperemesis gravidarum
Malignancy
Respiratory:
Gastrointestinal:
Urinary:
Musculoskeletal:
Dermatology:
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TAKING A SEXUAL HISTORY
Posted by Dr Anna Birtles and Dr Lewis Potter | Communication skills, History taking, Sexual Health
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Table of Contents
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Taking a sexual history is a key skill that all medical students need to learn. This guide discusses what
questions need to be asked and how they can be phrased when taking a sexual history.
It is really important to make sure you clarify the language the patient uses. “Sex” is not synonymous with
penetration, and personal preference over descriptive words for genitals should be acknowledged where
possible and appropriate. You also need to be aware of the array of social issues which you may come across
during the process of taking a sexual history (e.g. age of patient/partner(s), alcohol or drug intoxication,
partner notification, consent).
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“Today I need to take a sexual history from you, this is going to involve me asking some personal questions.
We ask these questions to accurately assess your risk of specific sexually transmitted infections, so please
don’t take any of the questions personally. Everything you tell me is confidential within the boundaries of
the team looking after your care. If however, we felt you or someone else was in significant danger, we
might have to break this confidentiality, to prevent harm. If you would prefer not to answer a particular
question or you’d like to stop the consultation at any point, please let me know.”
Gain consent:
Presenting complaint
It’s important to use open questioning to elicit the patient’s presenting complaint:
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Key symptoms to ask about
Genital skin changes
Vulval itching or soreness
Dysuria
Abnormal vaginal discharge
Abnormal vaginal bleeding
Dyspareunia
Abdominal or pelvic pain
Systemic symptoms (e.g. malaise, fever)
Pain
If the symptom is pain, you should use the SOCRATES structure for gaining further details:
Onset:
Character:
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Associated symptoms – “Are there any other symptoms associated with the pain?”
Time course – “What is the overall time course of the pain?” (e.g. worsening, improving, fluctuating)
Exacerbating or relieving factors – “Does anything make the pain worse or better?”
Severity – “On a scale of 0-10, how severe is the pain, if 0 is no pain and 10 is the worst pain you’ve ever
experienced?”
Vaginal discharge
All healthy women will have some degree of regular vaginal discharge, so it is important to distinguish
between normal and abnormal vaginaldischarge when taking a sexual health history.
You should ask if the patient has noticed any changes to the following characteristics of
their vaginal discharge:
Volume – “Have you noticed any change in the amount of vaginal discharge?”
Colour (e.g. green, yellow or blood-stained) – “Have you noticed any change in the colour of your
discharge?”
Consistency (e.g. thickened or watery) – “Have you noticed that your discharge has become more watery or
thickened recently?”
Smell – “Have you noticed any change in the smell of the vaginal discharge?”
Vaginal bleeding
Abnormal vaginal bleeding is an important symptom that can be relevant to a wide range of
gynaecological disease.
Post-coital bleeding:
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Potential causes include infection (e.g. chlamydia and gonorrhoea), cervical ectropion and cervical cancer.
Intermenstrual bleeding:
Potential causes include infection (e.g. chlamydia and gonorrhoea), malignancy (e.g. cervical or endometrial
cancer), uterine fibroids, endometriosis, hormonal contraception (e.g. Mirena coil) and pregnancy.
Questions to ask:
Dyspareunia
Dyspareunia refers to pain that occurs during sexual intercourse. It has several causes including sexually
transmitted infections (gonorrhoea and chlamydia), endometriosis, vaginal atrophy and malignancy.
Superficial dyspareunia – pain at the external surface of the genitalia (e.g. genital herpes)
Deep dyspareunia – pain deep in the pelvis (more common with gonorrhoeal or chlamydial infection)
“Do you ever experience any pain around the time of sex?”
“How long does it last?”
“When does it occur?” (before/during/after)
Location of the pain (e.g. superficial or deep) – “Does the pain feel to be within the vagina, or deep in your
abdomen?”
Nature of the pain (e.g. sharp, aching, burning) – “What kind of pain do you experience?”
Dysuria
Dysuria can be a symptom of a simple urinary tract infection, but may also indicate an underlying sexually
transmitted infection such as chlamydia, gonorrhoea, trichomoniasis or herpes.
Questions to ask:
104
“Do you feel you are passing urine more often?”
Vulval itching/soreness
Vulval itching and soreness are common symptoms which can be caused by a wide range of underlying
pathology including:
Candida (thrush)
Bacterial vaginosis
Genital herpes
Chlamydia
Gonorrhoea
Vaginal atrophy occurs in post-menopausal women and can lead to itching and bleeding of the vagina
Lichen sclerosis appears as white patches on the vulva and is associated with itching
Questions to ask:
Systemic symptoms
Sexually transmitted infections can also cause systemic symptoms such as:
105
Fever (secondary to pelvic inflammatory disease)
Malaise
Rash
Swelling of large joints, conjunctivitis and cervicitis (Reiter’s syndrome secondary to chlamydia)
Questions to ask:
Menstrual history
A menstrual history involves clarifying the details of a woman’s menstrual cycle.
Frequency:
Ectopic pregnancy
Sexually transmitted infections
Endometriosis
Malignancy (e.g. cervical, endometrial, ovarian)
Obstetric history
Current pregnancy (if relevant):
Gestation
Complications (e.g. small for gestational age)
Fetal movements – check they are normal if at an appropriate gestation
Symptoms
We have included a focused list of the key symptoms to ask people with a penis, followed by some
background information on each of the symptoms, should you want to know a little more.
107
Testicular pain and/or swelling
Testicular pain and swelling may suggest a diagnosis of epididymo-orchitis, which is often secondary to
chlamydia or gonorrhoea.
Questions to ask:
“Have you noticed any pain in your testicles?” (clarify the details of the pain using the SOCRATES method
mentioned previously)
“Have you noticed any change in the size of your testicles?”
Questions to ask:
Questions to ask:
“Have you noticed any lumps, bumps or ulcers around your penis, testicles or anus?”
“Are the lesions itchy or painful?”
“Have you noticed any tingling or burning in the area of the lesions?”
Urethral discharge
Urethral discharge may suggest underlying chlamydial or gonorrhoeal infection.
Questions to ask:
108
Dysuria (including frequency, urgency, nocturia)
Dysuria can be a symptom of a simple urinary tract infection, but may also indicate an underlying sexually
transmitted infection such as chlamydia, gonorrhoea or herpes.
Questions to ask:
“Do you have any pain or burning in your genitals when you pass urine?”
“Do you feel you are passing urine more often?”
“Is there any blood in your urine?”
Systemic symptoms
Sexually transmitted infections can also cause systemic symptoms such as:
Malaise
Rash
Swelling of large joints, conjunctivitis and cervicitis (Reiter’s syndrome secondary to chlamydia)
Questions to ask:
“Next, I’m going to move on to discuss your sexual history, some of these questions are quite in-depth and
personal. The reason we ask these questions is so that we can accurately assess the risk of sexually
109
transmitted infections. We ask the same questions to everyone, so please don’t take anything personally. If
you feel uncomfortable and would prefer not to answer, just let me know.”
Timing
Ask about the timing of the last sexual contact:
Consent
Ask if the patient feels this sexual encounter occurred with their consent:
Relationship
Ask if this was a regular sexual partner or a one-off casual sexual encounter:
Partner demographics
Clarify the sex and country of origin of the partner:
Contraception
Clarify the type of contraception used and the consistency of usage:
110
“Did you use any form of contraception for the sexual encounter?”
“Was there any issues with the contraception used?” (e.g. condom splitting)
“Was there any point at which contraception was not used during the sex?”
“Did you use contraception for every sexual encounter with this individual?”
“Have you had any other partners within the last 3 months?” – if so, repeat the above for each
Drug history
Current medications:
Recent antibiotics:
Social history
Smoking:
Alcohol:
Recreational drugs:
IV drug administration and sharing of the equipment used to snort cocaine increases the risk of acquiring
blood-borne viruses such as Hepatitis C and HIV
Also consider if it is appropriate to ask the age of partner(s), and be aware of safeguarding issues, especially
surrounding the social factors related to sexual encounters.
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Being able to take a thorough history of a transient ischaemic attack (TIA) or stroke is an important skill
that is often assessed in the OSCE setting. It’s important to have a systematic approach to ensure you don’t
miss any key information. The guide below provides a framework to take a thorough history. Check out the
stroke and TIA history taking mark scheme here.
TIAs and strokes both occur when the blood supply to the brain is interrupted. The difference occurs in the
definition of the timing: A stroke produces symptoms that last for at least 24 hours, whereas symptoms
produced by a TIA are transient (less than 24 hours), usually resolving fully within 30 minutes.
HPC
PAST MEDICAL HX
DRUG HX
FAMILY HX
SOCIAL HX
SYSTEMIC ENQUIRY
CLOSING THE CONSULTATION
MARK SCHEME (PDF)
114
Confirm patient details – name/DOB
Gain consent
A collateral history is often very valuable in the context of suspected stroke or TIA, particularly when the
patient is unable to communicate effectively.
Presenting complaint
It’s important to use open questioning to elicit the patient’s presenting complaint
“So what’s brought you in today?” or “Tell me about your symptoms”
Allow the patient time to answer, trying not to interrupt or direct the conversation.
In the context of stroke/TIA it’s also important to pay attention to how the patient is
communicating:
Onset of symptom(s):
115
Was the onset acute or gradual?
This can help differentiate between TIA and stroke as discussed above
If the patient is having an ischaemic stroke then this information is key in deciding if they are within the
therapeutic window for thrombolysis
If a patient has woken up with symptoms (but had none before going to sleep) the onset time is assumed to
be when they went to sleep
Severity:
Weakness: Try to clarify how weak (e.g. subtle, moderate, complete paralysis)
Sensory disturbance: Was the arm completely numb or did it just feel different to normal?
Visual disturbance: How much of the vision was affected? Was vision blurred or completely lost?
Intermittent or continuous: Is the symptom always present or does it come and go?
Precipitating factors: Was there any obvious triggers for the symptom?
Associated features: Are there other symptoms that appear associated? (e.g.
headache/nausea/vomiting/neck stiffness)
Previous episodes:
What frequency?
Ask the patient what their dominant hand is (useful to know before clinical examination)
116
Ask about any recent head or neck trauma (important if considering intracranial bleeding or carotid
dissection)
Severity of the weakness? (e.g. subtle, struggling with holding a cup, completely flaccid)
Sensory disturbance
Onset and duration of sensory disturbance?
Severity of sensory disturbance? (e.g. completely numb, tingling, feeling slightly different)
Visual disturbance
Onset and duration of visual disturbance?
Co-ordination problems
Does the patient feel their balance is poor?
Are they bumping into walls and door frames? (also consider visual field loss)
Does the patient think any of their limbs feels more clumsy?
Speech disturbance
Clarify type of speech disturbance:
Expressive dysphasia “I knew what I wanted to say, but I couldn’t get it out”
117
Receptive dysphasia “I wasn’t able to understand anyone, they were speaking jibberish”
Dysarthria “My speech was really slurred, it sounded like I was drunk”
Dysphagia is common in stroke and if not recognised can lead to aspiration pneumonia and choking
Headache
Has the patient experienced headache during this episode?
Did the headache start before or after the onset of other symptoms?
Generalised headache worse when lying down – consider raised intracranial pressure (e.g. haemorrhagic
stroke)
Nausea/vomiting
In the context of stroke consider either raised intracranial pressure (e.g. haemorrhagic stroke) or posterior
circulation ischaemic stroke (POCS)
Consider seizures which can occur in the context of haemorrhagic strokes and ischaemic strokes
Pain
If pain is a symptom, clarify the details of the pain using SOCRATES
118
Character: Sharp / dull ache / burning
Radiation: Does the pain move anywhere else?
Associations: Are there any other symptoms associated with the pain?
Time course: Worsening / improving / fluctuating / time of day dependent
Exacerbating/Relieving factors: Anything make the pain better or worse?
Severity: On a scale of 0-10, how severe is the pain?
Hypertension
Atrial fibrillation
Hypercholesterolaemia
Diabetes
Smoking
Concerns: Explore any worries the patient may have regarding their symptoms
Expectations: Gain an understanding of what the patient is hoping to achieve from the consultation
Summarising
Summarise what the patient has told you about their presenting complaint.
This allows you to check your understanding regarding everything the patient has told you.
It also allows the patient to correct any inaccurate information and expand further on certain aspects.
Once you have summarised, ask the patient if there’s anything else that you’ve overlooked.
Continue to periodically summarise as you move through the rest of the history.
119
Signposting
Signposting involves explaining to the patient:
What you have covered – “Ok, so we’ve talked about your symptoms and your concerns regarding them”
What you plan to cover next – “Now I’d like to discuss your past medical history, a bit about health conditions
in your family, your day to day life, and your medications”
Hypertension
Atrial fibrillation
Hypercholesterolaemia
Diabetes
Smoking
Carotid stenosis
120
Check when the episodes occurred and what deficits the patient developed (e.g. sensory disturbance,
weakness, visual disturbance)
Clarify what investigations they underwent and what treatment they received
Ask about residual deficits (e.g. after stroke) as it is useful to know the patient’s baseline function to
accurately interpret current clinical findings
Other neurological conditions – useful to be aware of as the patient may have pre-existing neurological
deficits as a result (e.g. multiple sclerosis)
Recent trauma to the head or neck – useful when considering intracranial bleeding and carotid dissection
Other medical conditions – clarify what other medical conditions the patient has, as they may be relevant
when considering treatment options for stroke or TIA
Surgical history:
Neurosurgery
Carotid surgery
Drug history
Antiplatelets or anticoagulant medication:
Aspirin
Clopidogrel
Warfarin
Apixaban
Rivaroxaban
Dabigatran
Family history
Stroke or TIA in first-degree relatives?
Clarify the age at which these conditions affected the patient’s family member
Social history
Smoking – How many cigarettes a day? How many years have they smoked for?
Diet
Living situation:
Does the patient have any carer input? (clarify the level of care)
Occupation – important to be aware of as the stroke or TIA may have implications on their ability to work
safely (e.g. if they drive for work/works at height)
Driving status:
If the patient drives then a TIA or stroke may result in temporary or permanent restrictions on their ability
to continue driving (this will depend on the clinical features of the episode and residual deficits)
Clarify the type of vehicle the patient drives, as heavy goods vehicles (HGVs) have different requirements
Systemic enquiry
A thorough history will also include a systemic enquiry. This can be helpful when considering other possible
causes for the patient’s presentation (e.g. infections, inner ear problems, psychomotor problems,
hypoglycaemia, seizures and cardiac syncope). It can also pick up on other problems the patient might be
experiencing. Choosing which symptoms to ask about depends on the presenting complaint and your level
of experience.
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LOSS OF CONSCIOUSNESS HISTORY TAKING – OSCE
GUIDE
Posted by Veronica Birca | Cardiology, History taking, Neurology
Table of Contents
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Loss of consciousness occurs when the function of both cerebral hemispheres or the brainstem reticular
activating system is compromised. The two major causes of transient loss of consciousness, syncope and
seizures, can be easily confused. When taking a history for an episode of transient loss of consciousness, it is
important to keep in mind the different possible causes. Throughout the interview with the patient, narrow
the differential diagnosis by asking targeted questions. Check out the loss of consciousness history taking
mark scheme here.
HPC
PAST MEDICAL HX
DRUG HX
FAMILY HX
SOCIAL HX
SYSTEMIC ENQUIRY
CLOSING THE CONSULTATION
MARK SCHEME (PDF)
Vasovagal syncope:
Carotid sinus hypersensitivity: triggered by sudden head turning, tight collar, shaving
Cardiovascular syncope
Loss of consciousness associated with decreased cardiac output.
Causes include:
Arrhythmia
Structural cardiovascular disease: coronary artery disease, valve disease, cardiac tamponade, hypertrophic
cardiomyopathy, aortic dissection
Structural pulmonary disease: pulmonary embolism
Orthostatic hypotension
Syncope associated with a sudden drop in blood pressure after standing up.
Causes include:
Seizure
Seizures are caused by abnormal excessive neuronal activity in the brain, leading to impairment of
normal cognitive function.
Seizures that involve a complete loss of consciousness are known as generalised seizures (either
convulsive or non-convulsive).
Causes
Metabolic disturbances – hypoglycaemia, electrolyte abnormalities, drug or alcohol intoxication, adrenal
insufficiency
125
Space-occupying lesions
Head trauma
Stroke
Gain consent
Presenting complaint
It’s important to use open questioning to elicit the patient’s presenting complaint.
Allow the patient time to answer, trying not to interrupt or direct the conversation.
“Ok, so tell me more about that.” or “Can you explain what that pain was like?”
126
History of presenting complaint
Effective history taking is key to narrowing the differential diagnosis when the presenting complaint is loss
of consciousness. A collateral history provided by someone who witnessed the episode is often required to
gain accurate details about what happened during and after the loss of consciousness.
Vasovagal syncope – emotional distress (fear, pain, instrumentation, blood phobia) // orthostatic stress
(prolonged standing)
Progressive light-headedness
Sweating
Nausea
Tinnitus
Seizures can also begin with subjective symptoms (called “epileptic auras”):
127
Olfactory or gustatory hallucinations (specific smell/taste)
Déjà-vu feeling
Cardiovascular syncope often lacks any prodromal symptoms, with the patient feeling ok and then
losing consciousness suddenly with no warning. You should, therefore, consider underlying
arrhythmia or structural heart disease if there is an absence of prodromal symptoms.
Were there any other symptoms occurring before the loss of consciousness?
Focal motor or sensory deficits: suggestive of focal seizures that may have then progressed to a generalised
seizure (causing loss of consciousness)
Palpitations: arrhythmia
Chest pain: myocardial infarction / pulmonary embolism / aortic dissection
Slow controlled collapse towards the ground is typical of vasovagal syncope
Motor
Flaccidity: cerebral hypoperfusion
Initial tonic stiffening, followed by clonic (jerking) movements of the extremities: generalized tonic-
clonic seizures
Duration
Syncope: <20 seconds typically
Other
Tongue biting (lateral aspect): generalized tonic-clonic seizure
128
Urinary or faecal incontinence: more common in seizure than syncope
Cyanosis can also occur in a prolonged seizure, but tonic-clonic movements precede cyanosis.
Seizure: post-ictal period of confusion and/or agitation lasting several minutes to hours (often not recalled
by the patient)
Other questions
Ask about any secondary injuries as a result of the loss of consciousness
Pacemaker (cardiovascular syncope) – also useful to know, as this can be interrogated to look for
arrhythmias at the time of the event
Patients with syncope and heart disease are at a markedly increased risk for ventricular tachycardia and
sudden death.
129
Drug history
Oral/subcutaneous hypoglycaemic agents (hypoglycaemia)
Beta-blockers (bradycardia/hypotension)
Recent changes (e.g. cessation of corticosteroid therapy potentially leading to adrenal insufficiency)
Family history
Cardiovascular disease (structural cardiac disease/arrhythmias/channelopathies)
Epilepsy
Diabetes
Social history
Smoking – How many cigarettes a day? How many years have they smoked for?
Alcohol – How many units a week? – be specific about type/volume/strength of alcohol (seizures caused by
withdrawal/intoxication)
130
Level of functional independence:
It’s important to understand the patient’s care needs, as this will influence how you manage them
Understanding the patient’s daily activities also allows you to consider the risk posed by further episodes of
loss of consciousness
Occupation:
Check what their job involves, as they may need to be advised to take time off work until a diagnosis is
established (e.g. someone working at heights)
Driving:
Depending on the suspected diagnosis there may be restrictions that result in temporary driving
suspension (e.g. seizure)
You should also check the kind of vehicle operated, as heavy goods vehicles often have different rules
Systemic enquiry
Systemic enquiry involves performing a brief screen for symptoms in other body systems, that are not
directly linked to the patient’s presenting complaint, but may, however, be relevant to the diagnosis.
Choosing which symptoms to ask about varies depending on the patient characteristics and his
presenting complaint.
Cardiovascular – Chest pain (myocardial ischemia) / Back pain (aortic dissection) / Palpitations
(arrhythmias)
131
Musculoskeletal – Joint/bone pain (fractures secondary to fall)
132
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Being able to take a breast lump history is an important skill that is often assessed in the OSCE setting. It’s
important to have a systematic approach to ensure you don’t miss any key information. The guide below
provides a framework to take a thorough breast lump history. Check out the breast lump history mark
scheme here.
HPC
PAST MEDICAL HX
DRUG HX
FAMILY HX
SOCIAL HX
SYSTEMIC ENQUIRY
INTERACTIVE MARK SCHEME
MARK SCHEME (PDF)
133
Confirm patient details – name/DOB
Gain consent
Presenting complaint
It’s important to use open questioning to elicit the patient’s presenting complaint
Allow the patient time to answer, trying not to interrupt or direct the conversation.
“Ok, so tell me more about that” “Can you explain what that pain was like?”
Is the lump’s size or discomfort related to the menstrual cycle in any way?
Pain – if pain is a symptom, clarify the details of the pain using SOCRATES
Eczema
Dimpling
Ulceration
Systemic symptoms
Weight loss
Fever
Lethargy
Other questions
Has the patient ever experienced similar symptoms in the past?
Onset – When did the symptom start? / Was the onset acute or gradual?
Severity – i.e. How much is the given symptom impacting on their life?
135
Intermittent or continuous? – Is the symptom always present or does it come and go?
Precipitating factors – Are there any obvious triggers for the symptom?
Concerns – explore any worries the patient may have regarding their symptoms
Expectations – gain an understanding of what the patient is hoping to achieve from the consultation
Summarising
Summarise what the patient has told you about their presenting complaint.
This allows you to check your understanding regarding everything the patient has told you.
It also allows the patient to correct any inaccurate information and expand further on certain aspects.
Once you have summarised, ask the patient if there’s anything else that you’ve overlooked.
Continue to periodically summarise as you move through the rest of the history.
Signposting
Signposting involves explaining to the patient:
What you have covered – “Ok, so we’ve talked about your breast lump and your concerns regarding it”
What you plan to cover next – “Now I’d like to discuss your past medical history and your medications”
Age at menarche/menopause
136
Parity
Drug history
Relevant prescribed medication:
Herbal remedies
137
Family history
Family history of breast disease – consider BRCA mutations
Social history
Smoking – How many cigarettes a day? How many years have they smoked for?
Living situation:
Occupation – Is the patient currently coping at work? What are their expected duties?
Systemic enquiry
Systemic enquiry involves performing a brief screen for symptoms in other body systems.
This may pick up on symptoms the patient failed to mention in the presenting complaint.
Some of these symptoms may be relevant to the diagnosis (e.g. back pain in metastatic breast cancer).
138
Choosing which symptoms to ask about depends on the presenting complaint and your level of experience.
GI – Appetite / Nausea / Vomiting / Indigestion / Dysphagia / Weight loss / Abdominal pain / Bowel habit
139
LOSS OF CONSCIOUSNESS HISTORY TAKING – OSCE
GUIDE
Posted by Veronica Birca | Cardiology, History taking, Neurology
Table of Contents
We’d really appreciate if you could leave us a rating
Loss of consciousness occurs when the function of both cerebral hemispheres or the brainstem reticular
activating system is compromised. The two major causes of transient loss of consciousness, syncope and
seizures, can be easily confused. When taking a history for an episode of transient loss of consciousness, it is
important to keep in mind the different possible causes. Throughout the interview with the patient, narrow
the differential diagnosis by asking targeted questions. Check out the loss of consciousness history taking
mark scheme here.
HPC
PAST MEDICAL HX
DRUG HX
FAMILY HX
SOCIAL HX
SYSTEMIC ENQUIRY
CLOSING THE CONSULTATION
MARK SCHEME (PDF)
Vasovagal syncope:
Carotid sinus hypersensitivity: triggered by sudden head turning, tight collar, shaving
Cardiovascular syncope
Loss of consciousness associated with decreased cardiac output.
Causes include:
Arrhythmia
Structural cardiovascular disease: coronary artery disease, valve disease, cardiac tamponade, hypertrophic
cardiomyopathy, aortic dissection
Structural pulmonary disease: pulmonary embolism
Orthostatic hypotension
Syncope associated with a sudden drop in blood pressure after standing up.
Causes include:
Seizure
Seizures are caused by abnormal excessive neuronal activity in the brain, leading to impairment of
normal cognitive function.
Seizures that involve a complete loss of consciousness are known as generalised seizures (either
convulsive or non-convulsive).
Causes
Metabolic disturbances – hypoglycaemia, electrolyte abnormalities, drug or alcohol intoxication, adrenal
insufficiency
141
Space-occupying lesions
Head trauma
Stroke
Gain consent
Presenting complaint
It’s important to use open questioning to elicit the patient’s presenting complaint.
Allow the patient time to answer, trying not to interrupt or direct the conversation.
“Ok, so tell me more about that.” or “Can you explain what that pain was like?”
142
History of presenting complaint
Effective history taking is key to narrowing the differential diagnosis when the presenting complaint is loss
of consciousness. A collateral history provided by someone who witnessed the episode is often required to
gain accurate details about what happened during and after the loss of consciousness.
Vasovagal syncope – emotional distress (fear, pain, instrumentation, blood phobia) // orthostatic stress
(prolonged standing)
Progressive light-headedness
Sweating
Nausea
Tinnitus
Seizures can also begin with subjective symptoms (called “epileptic auras”):
143
Olfactory or gustatory hallucinations (specific smell/taste)
Déjà-vu feeling
Cardiovascular syncope often lacks any prodromal symptoms, with the patient feeling ok and then
losing consciousness suddenly with no warning. You should, therefore, consider underlying
arrhythmia or structural heart disease if there is an absence of prodromal symptoms.
Were there any other symptoms occurring before the loss of consciousness?
Focal motor or sensory deficits: suggestive of focal seizures that may have then progressed to a generalised
seizure (causing loss of consciousness)
Palpitations: arrhythmia
Chest pain: myocardial infarction / pulmonary embolism / aortic dissection
Slow controlled collapse towards the ground is typical of vasovagal syncope
Motor
Flaccidity: cerebral hypoperfusion
Initial tonic stiffening, followed by clonic (jerking) movements of the extremities: generalized tonic-
clonic seizures
Duration
Syncope: <20 seconds typically
Other
Tongue biting (lateral aspect): generalized tonic-clonic seizure
144
Urinary or faecal incontinence: more common in seizure than syncope
Cyanosis can also occur in a prolonged seizure, but tonic-clonic movements precede cyanosis.
Seizure: post-ictal period of confusion and/or agitation lasting several minutes to hours (often not recalled
by the patient)
Other questions
Ask about any secondary injuries as a result of the loss of consciousness
Pacemaker (cardiovascular syncope) – also useful to know, as this can be interrogated to look for
arrhythmias at the time of the event
Patients with syncope and heart disease are at a markedly increased risk for ventricular tachycardia and
sudden death.
145
Drug history
Oral/subcutaneous hypoglycaemic agents (hypoglycaemia)
Beta-blockers (bradycardia/hypotension)
Recent changes (e.g. cessation of corticosteroid therapy potentially leading to adrenal insufficiency)
Family history
Cardiovascular disease (structural cardiac disease/arrhythmias/channelopathies)
Epilepsy
Diabetes
Social history
Smoking – How many cigarettes a day? How many years have they smoked for?
Alcohol – How many units a week? – be specific about type/volume/strength of alcohol (seizures caused by
withdrawal/intoxication)
146
Level of functional independence:
It’s important to understand the patient’s care needs, as this will influence how you manage them
Understanding the patient’s daily activities also allows you to consider the risk posed by further episodes of
loss of consciousness
Occupation:
Check what their job involves, as they may need to be advised to take time off work until a diagnosis is
established (e.g. someone working at heights)
Driving:
Depending on the suspected diagnosis there may be restrictions that result in temporary driving
suspension (e.g. seizure)
You should also check the kind of vehicle operated, as heavy goods vehicles often have different rules
Systemic enquiry
Systemic enquiry involves performing a brief screen for symptoms in other body systems, that are not
directly linked to the patient’s presenting complaint, but may, however, be relevant to the diagnosis.
Choosing which symptoms to ask about varies depending on the patient characteristics and his
presenting complaint.
Cardiovascular – Chest pain (myocardial ischemia) / Back pain (aortic dissection) / Palpitations
(arrhythmias)
147
Musculoskeletal – Joint/bone pain (fractures secondary to fall)
148
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Paediatric history taking differs significantly from a standard history for a number of reasons, the first being
that the patient may not be able to communicate, so a collateral history is often essential. In addition, there
are a number of extra topics you’ll need to cover, such as immunisation and developmental history. Check out
the paediatric history taking mark schemehere.
HPC
PAST MEDICAL HX
DRUG HX
FAMILY HX
SOCIAL HX
SYSTEMIC ENQUIRY
INTERACTIVE MARK SCHEME
MARK SCHEME (PDF)
Presenting complaint
Give the patient time to explain the problem/symptoms they’ve been experiencing.
It’s important to use open questioning to elicit the patient’s or parent’s presenting complaint.
“So what’s brought your child in today?” or “What’s brought you in today?”
This can sometimes be difficult when talking to children and you may need to adopt an approach
involving more direct questioning. So instead of saying “Tell me about the pain” you may need to ask
a series of questions requiring only yes or no answers.
“Is the pain in your tummy?” “Is the pain in your back?”
Severity – e.g. if the symptom is shortness of breath – are they able to talk in full sentences?
Intermittent or continuous? – is the symptom always present or does it come and go?
150
Precipitating factors – are there any obvious triggers for the symptom?
Relieving factors – does anything appear to improve the symptoms e.g. an inhaler
Associated features – are there other symptoms that appear associated e.g. fever/malaise
Pain – if pain is a symptom, clarify the details of the pain using SOCRATES
151
Concerns – explore any worries the patient/parent may have regarding the symptoms
Expectations – gain an understanding of what the patient/parent is hoping to achieve from the consultation
Summarising
Summarise what the patient/parent has told you about the presenting complaint.
This allows you to check your understanding regarding everything the patient/parent has told you.
It also allows the patient/parent to correct any inaccurate information and expand further on certain
aspects.
Once you have summarised, ask the patient/parent if there’s anything else that you’ve overlooked.
Continue to periodically summarise as you move through the rest of the history.
Signposting
Signposting involves explaining to the patient/parent:
What you have covered – “Ok, so we’ve talked about the symptoms”
What you plan to cover next – “Now I’d like to discuss any previous medical history”
Medical conditions
Previous surgery
152
Drug history
Regular medication – e.g. inhalers for asthma
ALLERGIES
Developmental history
Current weight and height – weight is required to calculate drug doses
Immunisations
Is the child up to date with their immunisations?
Dietary history
Type of food? – formula/breast milk/solids
153
Family history
Family history of disease – e.g. coeliac
Social history
Living situation – accommodation / main carer / who lives with child?
Parent’s occupation
Systemic enquiry
Systemic enquiry involves performing a brief screen for symptoms in other body systems.
This may pick up on symptoms the patient failed to mention in the presenting complaint.
Choosing which symptoms to ask about depends on the presenting complaint and your level of experience.
154
Respiratory – Dyspnoea / Cough / Sputum / Wheeze / Haemoptysis / Chest pain
GI – Appetite / Nausea / Vomiting / Indigestion / Dysphagia / Weight loss / Abdominal pain / Bowel habit
155
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Taking an alcohol history can be a bit daunting at first – especially as you’re asking questions which may
upset or anger a patient. However, it is important that history taking is as thorough as possible, so below is a
template to elicit this information (with some stock phrases for difficult questions, which you might find
handy!)
Personally, I find that signposting throughout allows the patient to prepare for more difficult questions, and
allows you to organise yourself – these are in quotation marks between the sections.
If anyone has any other ways of asking questions that they like, feel free to leave them in the comments. Check
out the alcohol history taking mark scheme here.
SCREENING
ALCOHOL INTAKE
IMPACT OF ALCOHOL
PAST MEDICAL HISTORY
PSYCHOLOGICAL ASSESSMENT
CLOSING THE CONSULTATION
INTERACTIVE MARK SCHEME
MARK SCHEME (PDF)
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Opening the consultation
Introduce yourself – name/role
“I’ve been asked to come and speak to you today regarding your alcohol intake. Is that okay with you?”
“I appreciate that some of these questions may be difficult, but it is important that you are honest. If you would
like to stop at any time, let me know.”
Screening
It’s useful to assess severity at this point and to get an overall idea of the person’s drinking habits.
The CAGE questionnaire comes in useful here! A score over 2 suggests problematic drinking.
“I’m going to ask some general questions about your alcohol use and how it affects you.”
C – Have you ever felt that you should cut down on your drinking?
A – Do you get annoyed if people comment on the amount which you drink?
E – Have you ever had an eye-opener? (A drink first thing on the morning to stave off a hangover – ‘”to stop
the shakes ” / “settle the nerves” / “hair of the dog”)
“Do you feel that you have a problem with alcohol?” (if so, enquire when this started/why)
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Details of alcohol intake
When did they have their first drink? – good/bad experience?
“If you stop drinking, do you…get the shakes/sweat a lot/feel sick/notice any physical changes?”
“Do you have to drink more than you used to, to get the same effects?” (tolerance)
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Psychological signs of withdrawal present?
“Have you been in contact with the police as a result of alcohol-related incidents?”
Living situation? – where do they live / who do they live with?
Here, it would be polite to thank the patient for divulging the information…
“Thank you for sharing that information with me. Now, we’ll move on from talking about alcohol to ask some
questions about your health at the moment.”
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Alcohol-use specific
Liver disease / peptic ulcers /pancreatitis /ischaemic heart disease
Drug history
Prescribed medication – “Are you prescribed any medication / Do you take it?”
Over the counter medication – Aspirin / St John’s Wort / other herbal remedies
Recreational drug use – “Do you take any other recreational drugs?”
Allergies
Ensure to document clearly any allergies stated.
Clarify what the allergic reaction was – e.g. lip swelling vs “a bit of a rash”
Family history
Focus particularly on history of alcohol/drug dependence
Psychological assessment
“Lastly, I’m just going to ask some questions about your mood. These may seem a little strange, but we ask
them to everyone who comes in with issues like this.”
Assess risk
Assess risk to self:
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Taking a depression history is an important skill often assessed in OSCEs. It’s a key skill that you’ll require
whichever speciality you’re heading towards. The guide below provides a structured framework to ensure
that all of the key points are covered in addition to some stock phrases that may come in handy. Check out
the depression history taking mark scheme here.
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Use the patient’s own language when describing their feelings, and use this to get them to expand on their
presenting symptoms. Repeating parts of phrases can help develop the consultation and show the patient
you are listening and trying to understand.
Be careful with your “active listening” fillers – nodding and making affirmative noises to show engagement
may be more appropriate than saying “Okay…”, you may accidentally re-affirm some of the patient’s
negative beliefs about themselves or their situation.
Don’t be afraid to (sensitively) ask about suicide risk. Screening for risk and asking about suicide does not
increase the likelihood of a patient attempting it!
Definition of depression
ICD-10 criteria
Depression is;
At least one of these, most days, most of the time for at least 2 weeks.
Sleep
Appetite
Concentration
Low confidence
Suicidality
Agitation
Slowing of movements
Guilt
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These will help you to determine the severity of depression, as shown in the table below.
Open questions can help the patient to explain how they are feeling, without placing words into their mouth or
assuming a specific reason for presentation.
Developing a rapport
Enquiring about mood and general feelings before jumping into a history may help the patient feel
more at ease:
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Screening for core symptoms
Screen for core symptoms of depression :
Biological symptoms
Sleep cycle
“Do you find you wake up early, and find it difficult to get back to sleep?”
Mood
“Are there any particular times of day that you notice your mood is worse?”
“Do you find that your mood gradually worsens throughout a day?”
Appetite
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“Have you noticed a change in your appetite?”
Libido
“Since you have been feeling this way, have you noticed a difference in your sex drive?”
Cognitive symptoms
Screen for, and assess the extent of any cognitive symptoms of depression.
Concentration
“Can you follow TV programmes/ read the newspaper/*insert hobby here* without getting distracted?”
Perception of self
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Ruling out differential psychiatric diagnoses
Identify any previous episodes of mania (rule out bipolar affective disorder diagnosis at this time)
When asking these questions, you may find it useful to use a lead-in. This allows you to signpost,
maintain the patient’s trust, and normalise any feelings they may have, enabling an open conversation.
“People who feel the way that you have been describing can experience some seemingly bizarre events
and feelings…”
“Have you ever heard voices speaking when there seems to be no-one around?”
“Do you ever feel that people are discussing you negatively?” (If so, get context!)
“Do you fear that people may be ‘out to get you’?”
“Have you ever felt that something or someone is able to put thoughts into your head?”
“Have you ever felt that something or someone can remove thoughts from your brain?”
“Have you noticed any sensations that seem odd or inexplicable?”
Assess risk
Assess suicide risk, and risk of harm to self.
Again, this is something that you may feel more comfortable approaching with a lead-in!
“When people feel down and depressed, they can feel that life is no longer worth living. Have you ever felt like
this?”
“Have you had any thoughts of taking your life?” (if so – how often, when) / “Have you thought of how you
would do something like this?” /“Have you made any plans?” / “Have you ever tried to take your own life?”
“Have you tried to hurt yourself in any way?” If so, how – if not “Have you thought of hurting yourself?”
“What things do you have that you feel stop you from harming/killing yourself?”
“Are you managing to eat and drink as you usually would?”
“Has your alcohol intake changed?”, “Have you been relying on anything to help you feel better? ” (Drugs,
alcohol, food, etc.)
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“Have you felt able to see your friends/socialise?”
“In the past, have you had any problems with your mental health?”
“Have you ever been admitted to hospital because of your mental health?” (If so, obtain details – time, method
of admission, result.)
Drug history
Note current medications and record allergy status
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“Are you prescribed any medication at the moment?” if so, check compliance
“Do you take any other medications?”
“Do you buy any medications over the counter?”
“Do you take any herbal remedies?”
“Has the dose changed of any of your medications recently?”
“Is there anything you are allergic to?” if so – note reaction
Family history
Enquire about any physical or psychological illnesses in the family.
A genogram may be useful – to account for family relationships and history of psychiatric illness in the
family.
Social history
Determine the social circumstances of the patient:
Assess the impact of the depressive symptoms on the individual’s relationships and work:
Elicit patient’s drug, smoking and alcohol intake, if not already elucidated:
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“Do you smoke?”
“Do you drink alcohol?”
“Do you take any other drugs?”
Insight
Assess if the patient has insight into their problem:
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HOW TO TAKE A MEDICATION HISTORY
Posted by Adam Rathbone | History taking, Information giving
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Many patients take multiple medications, prescribed by multiple professionals, in multiple settings.
Often information about medicines is poorly transferred, therefore a structured approach to the patient’s
medication history should be taken.
This guide can be used in two ways; to enhance any history that includes a drug history (including in an
OSCE) or specifically by professionals wanting to focus on collecting a detailed drug history, such as
pharmacists and pharmacy technicians or doctors and nurses during medication review consultations.
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Gain consent
Start by asking if the patient has any concerns about their medication?
If the patient does have concerns, try not to address them straight away, as without knowing the patient’s
full pharmaceutical history you can not really know how complicated their concern may be. If the patient
has a concern, say something like “we can come back to that once we know a little bit more about your
medication history.”
Example
“Hello, my name is Adam and I’m the pharmacist working on the ward today.”
“Can I confirm your name is [Mary Smith] and your date of birth is [12th July 1958]”
“I’d like to ask you some questions about your medication. Is that okay?”
“Before we start, do you have any concerns about your medication that you’d like to bring up?”
“We can come back to that issue once we know a little bit more about your medication history.”
4. How often?
This question provides two useful bits of information. Firstly it provides you with information about the
full dosing regimen by providing the frequency (e.g. the patient takes one pink capsule three times a
day). It also provides some information about the patient’s adherence to their treatment. In response to
this question, the patient may say ‘now and again’ or ‘every day’ and this can help you identify if their
presenting complaint may be due to medication non-adherence, including over and under-use.
5. Since when?
Knowing how long the patient has been taking a medication is important, as this changes the likelihood
of risks such as Type A pharmacokinetic effects (e.g. diarrhoea, hypoglycaemia, hypokalaemia), Type B
pharmacodynamic effects (e.g. anaphylaxis, blood dyscrasias) or Type C statistical effects (e.g. typically
only seen at cohort level when patients have been using medication for a long period of time e.g. gastric
ulceration with NSAIDs).
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injected etc). This is important to know as it may influence further investigations you may wish to do,
such as to explore the patient’s inhaler technique.
After gathering this information you should summarise your findings to the patient to double check you
have got the correct information.
You should ask the super six about each and every medication that is prescribed for the patient. You
may notice that some patients will start to readily volunteer the information as they predict which
question is coming next. Make sure to give the patient plenty of time to answer and try not to interrupt
them.
Example
“I’d like to start by finding out what medications you are prescribed by your GP or any specialists that
you see and dispensed by a pharmacy?”
3. How much (or how many)? How much of that do you take?
4. How often? How often do you take that? Is that [x] times a day regularly or just now and then?
6. How do you take it? On a typical day, how would you take that one? With food, or on an empty
stomach?
“Okay, just to summarise, you take [pregabalin] for [anxiety], [one capsule] [three times a day]. You
have been on it for [6 years] and you take it [regularly, on an empty stomach]. Is that right?”
This is an important part of the drug taking history, as many of these products will influence the
pharmacodynamic and pharmacokinetic properties of prescribed medication. For example, St John’s
Wort can increase the metabolism and therefore reduce the efficacy of oral contraceptives.
It is important to ask the patient where they source their non-prescribed medications. If the products are
purchased from a pharmacy, it is likely the product is high-quality and is what it says it is. However, if
purchased online or from overseas, then the patient may be using a poor quality product. If this is the
case, you should ask to see the product and ask the senior pharmacy team for support, particularly if
the pathology of the presenting complaint is unclear.
Example
“Do you take anything that you buy from a supermarket or over the internet?”
If yes, use the super six to find out more information about those products followed by:
Extra medications
When asking about prescribed and non-prescribed medication, patients often forget to mention products
that they may not classify as medications, such as eye drops, inhalers, sprays, patches or creams.
However, many of these products contain pharmacologically active ingredients that can cause or
exacerbate medical conditions.
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Example
“Do you take any eye drops, ear drops, inhalers, sprays, patches, injections, creams or ointments?”
When asking about extra medications, it can be helpful to point to your eyes, ears, mimic using an
inhaler or spray, applying a patch to the top of your arm, or applying a cream. This isn’t evidence-based
but it can trigger the patient’s memory (and can be entertaining to watch).
If the patient says they take any of those, use the super six to obtain a thorough history.
Asking questions about the patient’s lifestyle will also provide collateral information about their treatment
adherence. For example, someone who leaves at 5 am for a 90-minute commute to work is unlikely to
want to take their Furosemide first thing in the morning. Additionally finding out if the patient has any
support at home to take their medications may influence future prescribing decisions.
This is also a good opportunity to ask about any side effects or allergiesthe patient may have to any
medication.
Example
“I’m going to ask you some questions about your lifestyle now, is that okay?”
“Talk me through a typical day, from when you wake up to when you go to bed and how your
medications fit into that?”
Listen carefully to the patient’s response. Use the questions below to help clarify any missing
information.
Occupational history
“Do you work?”
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Support at home
“Do you have any help with your medications at home?”
Smoking history
“Do you smoke any tobacco?”
“How much?”
“How often?”
“Since when?”
Alcohol history
“Do you drink any alcohol?”
“What?”
“How much?”
“How often?”
“What?”
“How much?”
“How often?”
“How often?”
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Side effects
“Have you ever had any side effects to any medications?”
Allergies
“Do you have any allergies to medications?”
Providing information
Identifying the pharmaceutical care issue
At this stage of the consultation, you should revisit any concerns the patient may have had about their
current medication regime. It’s also important to give the patient the opportunity to raise any additional
concerns about their medication.
If you have identified your own concerns about the patient’s medication regimen, for example, if the
medication is not being used correctly, you should raise them for discussion with the patient in this part
of the consultation. The patient will be able to offer you their perspective and you can negotiate the best
way to address these concerns.
If a patient is unwilling to change the way they use a medication and you feel that they’re at high risk of
significant harm then you can say something like “I’m going to have to stop that medication because…”
Example
“You mentioned you were concerned about …. is there anything else you’re concerned about?”
“You mentioned that you miss your insulin now and again?”
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“I’m concerned about this because….”
“When you take ibuprofen that way it can upset your tummy and cause ulcers.”
“When you miss insulin it can cause problems for your diabetes.”
“When you crush your carbamazepine it may not work as effectively as it should.”
“Would you be interested in changing the way you use that medication?”
Reduce/increase dose
Additional therapy to deal with a side effect (e.g. adding a laxative following opioid-induced constipation)
Referral to a specialist pharmacist, medical consultant, GP or nurse if you have reached your level of
competence and require additional input
Short-term plan
The goal?
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Over how long?
Long-term plan
Example
“Okay, so in the short–term, we would like to reduce your dose of diazepam as you feel like it is making
you too drowsy.”
“Let’s change your dose from tomorrow so you take 5mg less.”
So for the next two weeks, you will only take one diazepam tablet each day.”
“I will give you a call in two weeks to see how you’re getting on. Is that okay?”
“I don’t think we need any additional monitoring or tests done at this point for anything. Is that okay?”
Closing
When closing the consultation it’s a good idea to summarise as much as you can, including the
information on the currently prescribed medication, the non-prescribed and the extras to make sure
nothing has been missed. You should also summarise the short term and long term plan so the patient
understands it fully and give the patient a final opportunity to ask any questions about what has been
covered and anything that has not been covered.
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Example
“Okay, so we’ve discussed your medication which included [two inhalers, your medication for anxiety,
pain, diabetes, epilepsy and headaches and the vitamins you buy over the counter]. The plan is to
reduce your diazepam by one tablet each day and I’m going to call you in two weeks to see how you
feel that is going and then review everything else again at your usual review appointment with the GP
surgery.”
“Do you have any questions about what we’ve covered in this consultation?”
“Do you have any questions about anything we haven’t covered that I may be able to help with?”
“If you think of anything afterwards, my name is Adam and you can get in touch with me by asking the
nurses to contact pharmacy/calling me on 1234 567 8912”
“Thank you”
Hospital records
The actual products (some patients bring their medication to consultations or hospitals in a Green Bag
which makes it much easier to check doses. Be wary that this medication is actually the patients and not
their partner’s or pet’s.)
Community pharmacy
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Following the consultation, you should try and record the information in the patient’s notes, including
what sources you used. It may be possible to add this to the patient’s current prescribed medication if
you’re using an electronic prescribing system or you may have to free-type or write out the information
directly into the patient’s paper notes. This can be time-consuming but try not to rush – many significant
patient safety incidents occur because medication-related information is transcribed incorrectly. Take
your time and double check that what you have documented is what you intended.
If you’re free typing/handwriting in paper notes, try and include the super six pieces of information for
each medication as a minimum as well as your short and long-term plan of action.
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PYREXIA OF UNKNOWN ORIGIN HISTORY TAKING
Posted by Nasreen Bahemia | History taking
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Introduction
Pyrexia of unknown origin (PUO) is defined as fever of 38.3°C or greater for at least 3 weeks with no
identified cause after three days of hospital evaluation or three outpatient visits.¹
Additional categories of PUO have since been added, including nosocomial, neutropenic and HIV-associated
PUO. ²,³
Autoimmune conditions (e.g. rheumatoid arthritis, mixed connective tissue disease, polymyalgia
rheumatica)
Check out the pyrexia of unknown origin history taking mark scheme here.
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HPC
PAST MEDICAL HX
DRUG HX
FAMILY HX
SOCIAL HX
SYSTEMIC ENQUIRY
CLOSING THE CONSULTATION
MARK SCHEME (PDF)
Confirm patient details – name and age (age-appropriate malignancies can be screened for)
Gain consent
Presenting complaint
It’s important to use open questioning to elicit the patient’s presenting complaint
Allow the patient time to answer, trying not to interrupt or direct the conversation
Duration – infectious causes become less likely with increasing duration of the fever
Severity – check if the patient has been recording their temperatures, and if so, ask about the readings
Progression:
Precipitating factors:
Was there any obvious trigger that preceded the onset of fevers?
Relieving factors:
Associated features:
Malaise
Nausea/vomiting
Night sweats
Fatigue
Rigors
Weight loss
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Previous episodes:
Infectious disease
Recent infections:
Type of infection
Symptoms
Ask what treatment the patient received and if they took it as prescribed (e.g. did they finish their course of
antibiotics?)
Local exposures:
Sick contacts
Tattoos/piercing
Travel history:
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Insect bites
Sick contacts
Sexual activity
Tattoos/piercing
Autoimmune disease
Symptoms associated with autoimmune disease include:
Rashes
Fatigue
Dry eyes/mouth
Red/painful eyes
Dry cough
Malignancy
Symptoms associated with malignancy include:
Night sweats
Weight loss
Fatigue
Haemoptysis/haematuria
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Enlarging masses
Bone pain
Type of infections
Symptoms
Frequency of infections (if very frequent may suggest partial treatment or immune deficit)
Conditions that increase the risk of infectious disease (e.g. diabetes, Crohn’s disease, immune system
impairment)
Autoimmune conditions:
Type of autoimmune condition (e.g. inflammatory bowel disease, rheumatoid arthritis, mixed connective
tissue disease, sarcoidosis)
The current level of disease control (is the patient currently experiencing a flare?)
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Malignancy:
Type of malignancy
Date of the last cycle of chemotherapy (if recent the patient may be immunocompromised)
Recent surgery
Splenectomy
Family history
Malignancies (e.g. leukaemias, lymphoma) – clarify age of onset and environmental risk factors
Autoimmune conditions (e.g. inflammatory bowel disease, rheumatoid arthritis, mixed connective tissue
disease)
Infectious diseases (e.g. TB) – relevant if the patient has regular contact with the individual
Medications
Regular medications:
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Ask about any recent changes, such as new medications or changes in dose
Antibiotics:
Type of antibiotics
Duration of treatment
Patients with autoimmune disease or organ transplant recipients are often taking
immunosuppressive medication, so you need to clarify what they are currently (or have recently)
taken:
Long-term steroids
Azothiaprine
Methotrexate
Tacrolimus
Mycophenolate mofetil
Chemotherapy – if a patient is receiving chemotherapy there are several details you should clarify:
Type of chemotherapy
ALLERGIES – always ask about drug allergies and clarify the details surrounding each
Social history
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Occupational exposure (e.g. healthcare workers, exposure to animals)
Recreational drug use – clarify if drugs are administered intravenously as this is a significant risk factor
for infection (e.g. endocarditis)
Systems review
Localising symptoms associated with infection:
Rashes – lupus (butterfly rash), sarcoidosis (erythema nodosum), adult-onset Still’s disease (salmon-pink
coloured)
Morning stiffness and joint swelling – rheumatoid arthritis, psoriatic arthritis
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Raynaud’s phenomenon can occur in many connective tissue diseases (e.g. rheumatoid arthritis, systemic
lupus erythematosus, systemic sclerosis)
Headache, jaw claudication, scalp tenderness, vision loss – suggestive of giant cell arteritis which is
associated with polymyalgia rheumatica
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