A Step by Step Guide to Mastering the Osce

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(1)A Step By Step Guide To Mastering The OSCEs. Edited by. A. Alimari, MD. 2006 1.

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(3) To My parents, wife, and daughters. 3.

(4) Copyright © 2005-2006 MedInfo Consulting. All rights reserved. No part of this ebook may be copied, reproduced, distributed, or transmitted in any form by any means graphic, electronic, or mechanical without express permission in writing from MedInfo Consulting. Your friends and colleagues are NOT an exception. Protect yourself.. 4.

(5) Content Part One. The Medical Interview. Chapter 1. Introduction.. 11. Chapter 2. OSCE Exam Formats.. 15. Chapter 3. The OSCE Examiner’s Checklist.. 17. Chapter 4. Physician-Patient Communication Skills.. 19. Chapter 5. How To Prepare For The OSCEs.. 21. Part Two. History Taking Interview. Chapter 6. The Model.. 29. Chapter 7. The Minute(s) Before.. 33. Chapter 8. Self-Introduction.. 35. Chapter 9. Chief Complaint.. 37. Chapter 10. History of Present Illness (HPI).. 39. Chapter 11. Station Appropriate Questions.. 41. Chapter 12. Standard Questions.. 77. Chapter 13. Wrap Up.. 81. Chapter 14. Counseling Stations.. 83. Part Three. Physical Examination Interview. Chapter 15. Physical Examination Interview.. 89. Chapter 16. Chest Examination.. 91. Chapter 17. Cardiovascular Examination.. 97. Chapter 18. Abdominal Examination.. 103. Chapter 19. Gynaecological Examination.. 111. Chapter 20. Hematological Examination.. 113 5.

(6) Content. Chapter 21. Head and Neck Examination.. 115. Chapter 22. Neurological Examination.. 119. Chapter 23. - Cranial Nerves Examination.. 119. - Mini Mental Examination.. 129. - Motor Examination.. 131. - Sensory Examination.. 139. - Coordination Examination.. 144. Musculoskeletal Examination.. 149. - Sub Model.. 149. - Tempomandibular Joint exam. 152. - Shoulder Exam.. 152. - Elbow Exam.. 154. - Wrist Exam.. 155. - Hand Exam.. 157. - Cervical Vertebrae exam. 160. - Thoracic Vertebrae exam.. 163. - Lower back Exam.. 166. - Hip Exam.. 169. - Knee Exam.. 173. - Ankle Exam.. 178. Chapter 24. Pediatric examination.. 183. Chapter 25. Obstetric examination.. 191. Part Four. Emergency Room. Chapter 26. Emergency Room Stations.. Suggested Readings. 6. 199 121.

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(9) PART ONE THE MEDICAL INTERVIEW. 9.

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(11) Chapter 1: INTRODUCTION Objective Structured Clinical Examination, OSCE, also called Objective Standardized Clinical Examination is tough. OSCE exams are really difficult and stressful. That is what is it. I’m not going to say it is not, as what clinical educators and OSCE organizers claim trying to make it acceptable for you. OSCE Exams consist of several clinical encounters (called stations) with specially trained actors playing the role of a patient with some sort of a medical complaint (called Standardized Patient, SP). Let’s take a minute here to absorb your situation during the OSCE. This is an important step as you may realize that the first step to deal with any issue is to completely understand what is it. You will find a lot of articles and web pages describing what are the OSCE exam procedures. They present the OSCE in a scientific academic context. I am sure you have already read several of these. Are you? Have you read between the lines? Have you achieved an understanding about how your physical and mental status will be during the OSCE exam? Well, let me explain it for you. Just concentrate. Imagine yourself in a hallway with several other candidates each standing in front of a closed door. Several individuals are watching you for any violation of the exam rules. Then an announcement/buzzer sounds. You have one or two minutes to read a full page hanged on that door describing what the station ahead is about and what is required to do. Usually, you’ll need to read the instructions again because you’re nervous, you heart is racing and your mind isn’t catching what your eyes are reading! Then, a second announcement/buzzer sounds. You knock the door and enter the room. In each room you will find two strangers and a different room setting. In some OSCEs, like USMLE Step 2 CS, there is no examiner in the room, just the SP. You have to hand out one or two of your stickers if present. You may have even looked for the stickers and didn’t find them. Then you have to start as your limited time has already started when the second announcement/buzzer went on. You need to get information from the SP or may be examine or consult him/her. Your voice is low. Your hands are shaking. You look unconfident and don’t know what to say or do. These SPs are well trained not to give you any information unless you specifically ask for it. Unlike real life medical encounters where the patient will say everything when you ask about the reason for their visit. Obviously, you have to know what questions you need to ask to save time. As you were asking, the patient replies by questions for you. Questions like ‘What do you mean?’, ‘Do I have to answer that?’, ‘Is this relevant to my problem?’, ‘Why are you asking this?’ All these questions are intended to shake you if that wasn’t a reflex to your poorly phrased questions. You start to. 11.

(12) The Medical Interview: Introduction lose control over yourself and the encounter. You start to make fatal mistakes like being disrespectful to the patient and unprofessional. And you’ll forget to ask questions that are important to fulfill the examiner checklist! That examiner who is sitting or standing closely observing you or assessing you through the video monitor. Suddenly the announcement/buzzer goes on again. The station is over. Oh my God. There are still tons of questions that I have to ask. I missed this station. You’ll start the process of self-blaming. Then you’ll try to hold yourself together. As you proceed, you’ll find that you had already wasted substantial time of the ‘minute before’ of the next station. The cycle starts again. By the fourth or fifth station, you’ll feel exhausted and headache starts. You’ll feel unable to think about the coming station and you’ll start to give up claiming that you’ll do you best, hopelessly. Did you get what I wanted you to understand? Let me put it in summary: You will be nervous, irritable and cannot think straight. You will be physically and mentally exhausted. Your time is running fast and by all means is not enough. Some SPs will be challenging you intentionally and waist your time. You need to be organized and manage your time efficiently. You need to know in advance what to ask, as there is no time to think. You need to be careful about how to phrase your questions and comments in order to be respectful and empathic. You need to ask your questions intelligently in order not to lead the patient or trigger programmed time wasting and problem evoking conversations. You need to be and appear confident and professional. Is that easy? Of course not. Is it impossible to do? Of course not. Thousands of medical students and graduates have done it. Okay, so it is not easy and also not impossible at the same time. The key is you need to know how to do it and assign the needed time and effort to prepare yourself to the OSCEs by practicing over and over the same steps. You’ll be just fine. But how to prepare yourself? This book, A Step By Step Guide To Mastering The OSCEs, will help you to: Know how to prepare yourself for the OSCEs. What and how to ask in each of these stations. How to communicate in the OSCE exam. How to perform a complete physical exam accurately and respectfully. How to be respectful, attentive and caring. How to appear organized, confident and professional. Let’s start. I can help you pass the OSCEs with high score. You can do it. You just need someone to show you specifically how and I can help. Let’s start.. 12.

(13) Chapter 2: OSCE EXAM FORMATS Objective Structured Clinical Examinations (OSCEs) stations in USMLE Step 2 CS, USMLE Step 3, MCCQE II, PLAB part 2 and medical schools clinical exams or international/foreign medical graduates clinical skills assessmnets are differently designed to assess one or more of your clinical skills depending on the purpose of that exam. However, the required medical knowledge, clinical skills, and communication skills are the same among these OSCEs. It is important to fully understand what is exactly required to be performed in each station and to what medical extent. You will be assessed for only those skills asked for in that station. Tasks other than those requested or more than expected at this stage of your medical knowledge, regardless of whether you performed them correctly or not, wont be counted and most critically will waste your valuable limited time. The length of the OSCE station is generally 5-20 minutes. You will perform a medical encounter with a standardized patient (SP) just like a real medical encounter. An examiner (a physician) may be present during these encounters to assess your clinical skills and communication skills based on a standard checklist. Otherwise, the encounter is video monitored. A nurse may also be present in emergency management stations to receive management orders from you and inform you about the progress. There are mainly four OSCE formats:  Focused History Taking OSCEs  Focused Physical Examination OSCEs  Consult OSCEs  Emergency Room OSCEs Combination of the above formats is common in long OSCEs, like a focused history taking and a focused physical examination, or a focused history taking and a consult.. Focused History Taking OSCEs Focused history taking OSCEs are data gathering stations. Here you will show your medical knowledge concerning the current specific patient case. This is what is meant by focused. This will include; exploring the chief complaint, history of present illness, past medical and surgical history, medications and allergies, family history and social history, occupational history, and sexual history relevant to this case scenario. Although OSCEs are a simulation of simple straightforward common real life presentation, please note that 'focused' does not mean skipping the differential diagnosis. However, the SP role might not be simple. Some history taking OSCEs will have some difficult to deal with patients or ethical issues to be assessed too, like a depressed patient who is unwilling to talk, or a failed to thrive child with a hidden child abuse issue, ..etc. In addition to assessing your medical knowledge, your communication skills 13.

(14) The Medical Interview: OSCE Exam Formats and approach to gather data are also assessed. This is an important part of the station’s final mark.. Focused Physical Examination OSCEs In focused physical examination OSCEs, you have to examine the requested body part or system. No head to toe examination. But, if the complete examination of a system requires examining some other body parts, then it is included. For example, a complete cardiovascular examination will include examination of the legs for peripheral pulses and edema as well as opthalmoscopy for cardiac related retinal changes among others. Please, explain every thing you are going to do to the patient taking necessary permission before you proceed. Pay attention to patient’s privacy and draping. Don't harm or repeat harmful maneuvers. If an examiner is present, stand in a way to let him/her watch you and also explain what are you doing giving the findings.. Consult OSCEs Consult OSCEs are talk stations. You will be asked to explain a diagnosis, a prognosis, a lab or medical imaging test result, a drug interaction or side effect, a procedure, an alternative, or any patient’s concern. Ethical stations are mostly consult stations like breaking bad news, obtaining consents,.. etc. There will be some history taking too and some times it will be a combined focused history taking and a consult station. Consult OSCEs require good communication skills as well as good English language skills. These skills usually weigh up to 60-70% of that station final mark. It is obvious how important to develop your language and communication skills. Being attentive and respectful is a must. Your ability to transfer relevant information to the patient in an understandable simple way will be assessed. That is being a good health educator and health promoter.. Emergency Room OSCEs There are three types of emergency room OSCEs scenarios. The ER management scenario; The post management ER consult, and; The ER stable patient as walk-in scenario. In ER management OSCEs, you will be asked to manage the case. A nurse will be present to take your orders and pass back results and patient’s progress. In the post management ER consults, you will be asked to consult the patient for discharge, dealing with ethical issues like breaking bad news, organ donation, or abuse. In the ER stable patient as walk-in scenario, you will be asked to perform any task just like any office setting like history taking, physical examination, or consult.. 14.

(15) The Medical Interview: OSCE Exam Formats So, read the instructions carefully before entering the room to sub-classify the ER station to one of the above types as your task will be different. ER OSCEs require a lot of training and practice to perform all the requested tasks accurately and efficiently. It is very important to show confidence and control of the situation.. Post Encounter Probe (PEP) Some OSCEs end with a one or two-minute oral questions period usually called "Post Encounter Probe (PEP)" (Not in USMLE). During this time, you are not allowed to talk to the SP but only with the examiner. The examiner will ask you 2-4 standard questions that are usually concerning:  What is your one working diagnosis for this patient?  What is your three most relevant differential diagnosis?  What are the risk factors of this patient?  What is your only / three investigation you are going to order for this patient and why?  What is your initial / short term plan of management?  What is your long term plan of management?  Interpret this lab findings / imaging...etc.  Prognosis? If this patient came back in .. days / weeks with .. what will be your explanation In a matter of fact, you should organize your study material for any medical topic in your preparation to both written and clinical exams to cover the above listed aspects. Some OSCEs alternate with a period of written questions PEP covering the same upper listed questions.. Patient Note (Write ups): In USMLE Step 2 CS, the patient note 10 minute post encounter period will be the ordinarily patient medical chart/record note in addition the above issues.. Patient Write ups: These are writing admission, discharge, progress, follow up, pre-op, post-op notes in the patient’s chart. Referral and thank you letters are sometimes requested too. These are pretty simple. There are several ready to fill out forms and instructions over the internet. Pick few of them, memorize them and practice filling up them. There are few other modified formats that fall into one of the above listed types, such us: Consult over the phone with a patient, a caregiver, or another physician. In this scenario, you will find inside the OSCE exam room a phone and some one is talking on the other side of the phone line. Commonly it will be a mother having an acute problem with her child. Another common scenario is a physician. 15.

(16) The Medical Interview: OSCE Exam Formats from a rural hospital wants to arrange for the transfer of his acute case patient to your hospital. Here, just go through the same set of questions that you ask a patient attended to your office. Make sure to take the caller name, position and relation to the patient. No transfer of unstable patients. Be aware of privacy issues and releasing patient information over the phone. Interpretation of diagnostic materials such as labs, microscopic, ECGs, X-rays, CT.. etc. Presenting the case to the examiner. That may include a differential diagnosis, and/or a plan for immediate and/or long term managements as an evaluation of your clinical reasoning. Performing practical skills by using manikins. Such as venepuncture, inserting a cannula into a peripheral vein, suturing a wound, vaginal bimanual exam, rectal digital exam, PAP smear, breast exam, testes exam, prostate exam, ophthalmoscope, diagnostic procedures, basic cardio-pulmonary resuscitation (adults and children), performing urinary catheterization, mixing and injecting drugs into an intravenous bag, giving intramuscular and subcutaneous injections, safe disposal of sharps .. etc. Some of these may also be included in or at the end of the above formats. As you know, all medical students and graduates will take several OSCEs during their medical life starting from the medical school OSCEs then any of USMLE Step 2 CS, USMLE Step 3, MCCQE 2, or PLAB 2 OSCEs. So, develop your clinical skills and use them repeatedly during the OSCEs and, for your benefit, also later in your practice. As in each station within the same exam day you'll encounter a different standardized patient and examiner with each station. So, you may repeat the same skills and even the same words, phrases, and descriptions. Assessment of each station is done separately by different evaluators.. 16.

(17) Chapter 3: OSCE EXAMINER’S CHECKLIST Objective Structured Clinical Exams (OSCEs) cases cover common and important situations that a physician is likely to encounter in common medical practice in clinics, doctors’ offices, emergency departments, and hospital settings in real practice. Thus, you’ll be evaluated as if it is a real life practice. OSCE exams use standardized patients (SP), i.e., people trained to portray real patients. These SPs follow a certain script to play with you during the encounter. These scripts are written in details including patient general look, cloths, gestures, emotions, and all negative and positive answer. It also includes any unexpected behaviours such as the SP turns agitated, upset, violent, restless, impolite, or leaves the room during the encounter. As SPs follow strictly these scripts, OSCEs examiners also have a standard printed checklist or blueprint for each station that they have to fill out while observing you. These checklists are standardized to reduce examiners' bias. On these checklists, there are station specific points and a general performance points to be assessed. There are up to 40 points to be check in each station. Some OSCEs may also include a checklist to be filled out by the standardized patient. SPs will reveal information when specific related questions are asked. They wont voluntarily give you information as some times happen in real life patient encounters. For example, if you don't ask about all their medication now and in the past, they wont show you a printed list of their medication. In some OSCEs, SPs are instructed to follow different paths or ask specific questions according to your performance. For example, turning uncooperative if you are not responding to their concerns or gestures.. What is the OSCE Examiners' Checklist? Checklists are organized to assess the followings:  Medical knowledge specific to this station, such us, symptoms, signs, associated factors, risk factors, prevalence, complications, prognosis, management plans, .. etc.  Data gathering skills: Your way of patient information collection by history taking and physical examination.  Documentation – completion of a patient note summarizing the findings of the patient encounter, diagnostic impression, and initial patient work-up.  Communication and Interpersonal Skills:  Initiation of interview: acknowledgement of patient, introduces self, at ease, attentive to patient.  Questioning skills: e.g., use of open-ended questions, transitional statements, confident and skilful questioning, appropriate language, use of different question types, or awkward, exclusive use of closed 17.

(18) The Medical Interview: OSCE Examiner’s Checklist ended or leading questions, jargon, interrupts patient inappropriately. Information-sharing skills e.g., None given, avoidance of jargon, responsiveness to patient questions or concerns, provision of counseling when appropriate, confident and skilful at giving information, attentive to patient understanding; truthful. Professional manner and rapport e.g., Condescending, offensive, aggressive, judgmental, negative attitude to patient, or polite and interested, warm, polite, empathic, concern for patient's comfort and modesty, examinee's attention to personal hygiene, expression of interest in the impact of the illness. Listening skills: Interrupts patient inappropriately, impatient, or attentive to patient’s answers and concerns. Organization of interview: Scattered, shot-gun approach, logical flow, purposeful, or integrated handling of encounter Closing: Abrupt, or acknowledges end of interview, or attempts closure, or clear closure, or organized, thoughtful closure. Ethical conduct: Markedly inappropriate or awkward handling of ethical issues, or considers and responds to ethical issues with care and effectiveness. Compliance optimization: Did the candidate do everything possible to optimize the patient’s compliance? Physical examination: No consent, awkward, uses jargon, no interaction or acknowledgment of patient, or clear, concise instructions, elicits consent to physical examination, at ease with patient. Attention given to patient's physical comfort: Inattentive to patient's comfort or dignity; e.g., no draping and/or causes pain unnecessarily, or consistently attentive to patient’s comfort and dignity. Organization of physical examination: Scattered, patient moved unnecessarily, logical flow, purposeful, integrated handling of examination. Spoken English Proficiency: Clarity of spoken English communication within the context of the doctor-patient encounter (e.g., pronunciation, word choice, and minimizing the need to repeat questions or statements).. In every sentence you say during the medical encounter, you should have taken care of all the above elements. Difficult?… Yes, but not impossible. In this book you will find sentences that were carefully chosen to meet all of the above requirements. This will definitely save you a lot of effort and time.. 18.

(19) Chapter 4:. PHYSICIAN-PATIENT COMMUNICATION SKILS. OSCE exam is an assessment of clinical knowledge, skills, and attitude. The communication skills you demonstrate and the process you go through in obtaining a history or performing a physical examination are more important than determining the diagnosis. Communication skills are verbal and non-verbal words, phrases, voice tones, facial expressions, gestures, and body language that you use in the interaction between you and another person. Verbal communication is the ability to explain and present your ideas in clear English, to diverse audiences. This includes the ability to tailor your delivery to a given audience, using appropriate styles and approaches, and an understanding of the importance of non-verbal cues in oral communication. Oral communication requires the background skills of presenting, audience awareness, critical listening and body language. Non-verbal communication is the ability to enhance the expression of ideas and concepts without the use of coherent labels, through the use of body language, gestures, facial expressions and tone of voice, and also the use of pictures, icons, and symbols. Non-verbal communication requires background skills such as audience awareness, personal presentation and body language. Effective communication is an essential part of building and maintaining good physician-patient and physician-colleague relationships. These skills help people to understand and learn from each other, develop alternate perspectives, and meet each other’s needs. Hidden agendas, emotions, stress, prejudices, and defensiveness are just a few common barriers that need to be overcome in order to achieve the real goal of communication, namely mutual understanding. High Performers master and continually practice the basics, as well as prepare for these communication pitfalls. Just as successful physicians routinely practice basic medical skills, High-Performers understand that they too must pay attention to communication skills or they risk getting out of shape pretty quickly. Communication skills in a medical setting may include the way you use for:  Explaining diagnosis, investigation and treatment.  Involving the patient in the decision-making.  Communicating with relatives.  Communicating with health care professionals.  Breaking bad news.  Seeking informed consent/clarification for an invasive procedure or obtaining consent for a post-mortem.  Dealing with anxious patients or relatives.  Giving instructions on discharge.  Giving advice on lifestyle, health promotion or risk factors. 19.

(20) The Medical Interview: Physician-Patient Communication Skills Your approach to the patient will be assessed all through the encounter, but in some stations communication will be the main skill for which you will be awarded marks. In OSCEs, as well as in life, two aspects of the communication skills are important. The way you choose for your approach to reach the other person, and the effects and outcome of your efforts. The OSCEs examiners will be considering your:. Approach to the patient You should: Introduce and orientate the patient and yourself. Establish an attentive, respectful and non-judgmental relationship. Acknowledge the patient's emotions and concerns.. Listening, questioning and diagnosing You should: Ensure you have understood the patient's symptoms/problem and concerns. Summarize and clarify understanding.. Explaining and advising You should: Enable the patient to understand the problem/situation. Reassure appropriately. Summarize and clarify understanding.. Involving patient in management You should: Explore the patient's expectations/concerns. Propose/ explain management plan clearly. Explore the patient's response. Respect the patient's autonomy, and help him or her to make a decision based on available information and advice. Summarize and clarify understanding. Communication skills are learnable, trainable, adaptable just like any other skill!. Yes, it is not easy to change yourself. But it wasn't easy to be in your current academic achievement either. You can teach yourself these skills, learn them, adopt them, and make them part of the new you! The new medical student or graduate, or even a new start towards being a successful physician!. In this book, you won’t find information for nonverbal communication. Verbal communications are addressed through out you statements in this book. For more information check the ebook: “How To Maximize My Communication Skills For The Medical Encounter”. 20.

(21) Chapter 5:. HOW TO PREPARE FOR THE OSCES. There are three aspects that you should take care of simultaneously in your preparation for the OSCEs:  Medical knowledge and clinical skills.  Communication skills.  An approach for the medical encounter.. Medical knowledge and clinical skills: You need to refresh your basic medical knowledge relevant to the OSCEs. This means you should re-study medicine based on common patients’ complaints and physical finding and not based on topics. No patient will come complaining of endometriosis or asking for TB treatment! Patients come to you complaining of symptoms like shortness of breath or a long standing cyclic pelvic pain. For each complaint, find answers to following questions and memorize them: 1. What are the five most common relevant differential diagnoses? 2. How to differentiate between these five diseases? What key elements in history, physical examination, and investigations will help? 3. What are the risk factors of each of these diseases? 4. What is your only / three investigations you are going to order for this patient and why (To differentiate between the diseases)? 5. What is your initial / short term plan of management for each of these diseases? 6. What is your long term plan of management for each disease? 7. Interpret the lab findings / imaging...etc. concerning each disease. 8. Prognosis of each disease? What to inform the patient about what to expect in the near and far future? 9. Complications of each disease? How to prevent them? If this patient comes back in ... days / weeks complaining of ...., what will be your explanation? 10. What are the key issues that you have to ask or counsel the patient about? Write down the above questions and answer it for each symptom. Memorize it. In a matter of fact, this should be your approach to prepare for the written exams too as it is extremely helpful. Written exams are getting more and more clinically oriented. This is the best quick and focused approach to an efficient practice. There are several valuable books and resources that deal with common symptoms and signs and differential diagnosis. Check your local medical library or ask your colleagues and instructors. Clinical skills include history taking, physical examination, counseling, and clinical reasoning. This includes the way you perform these skills too.. 21.

(22) The Medical Interview: How To Prepare For The OSCEs. Communication skills: Your second aspect of preparation for the OSCEs is the most important, your communication skills In OSCEs, verbal and non-verbal communication skills are very important both directly and indirectly. Directly, by showing respect, professionalism, attentiveness, care, interest, and efficiency in acquiring medical data gathering. Indirectly, by leaving a good impression on the OSCE examiner and the standardized patient minds through your look, voice tone, and facial expressions. These two persons will score your performance according to a checklist. OSCE organizers try their best to minimize personal bias from these two. However, what if your performance lies between two categories? Your performance was less than good but better than intermediate, for instance, which one to be checked for you? Here, their impression about you will act for or against you. They will think; either, he/she is better than this but the exam stress made him/her perform less than usual! Or, that is what actually looks like his/her real everyday performance! Do you get it? This will push you one level up or down! I don’t know how to stress the importance of communication skills in OSCEs and in real life practice too. In fact, it is what makes you a good or bad physician in the eyes of your patients in the future. Tell me, how many doctors do you know who are scientifically average but are very famous and rich! … On the other hand, how many doctors do you know who are scientifically excellent but are unknown and their practices are barely making a living! Work on improving your communication skills. It is not what you are and that’s it. Bad communications can be developed, improved, or even eliminated if it is harming you, right?! Yes, sometimes, it is not easy but it is not impossible. Start now. Rebuild the way you look, speak, and behave. Yes, rebuild what you’ve grown up with for a better you for your benefit. Your behavior with people may be sending the wrong message about who are you, or let’s say an inappropriate message for the current context! What about cultural diversity? Some behaviors that are acceptable in your culture may be unacceptable in other cultures or even professionally. So, how to evaluate your communication skills? First, know how are you doing. Assess your current communication skills. Assess your posture, look, hand and head movements, and facial expressions. Assess your voice and tone. Do that by: Watching yourself in a mirror while practicing or videotape your practice and play it back several times focusing on one aspect at a time. Be honest with yourself. Criticize your behavior as if you are assessing someone else. Write done positive and negative behaviors. This might be difficult as your Ego will stand up to defend yourself!. We believe we are perfect or at least suitable. Be honest for the benefit of yourself. The only drawback here is you may not know which is an appropriate behavior or gesture and which is not. 22.

(23) The Medical Interview: Notes  The second step is to ask a close friend or relative to watch you and assess. Choose someone who cares for you. Explain to him/her what aspects you want them to watch closely. Make it mutual. If they are preparing for the OSCE too. Assess each other and be open minded constructive and honest.  Finally, read books or attend course about communication skills and ethics in a medical context. Have a look on “How To Maximize My Communication Skills For The Medical Encounter”.. An approach for the medical interview: The third aspect of your OSCE preparation is to develop and practice a specific approach to the medical interview. In OSCEs, as well as in real life medical practice, you have limited time and resources. It is only 5-20 minutes long interview. And you have to ask so many questions, figure out what is wrong with this patient, while being gentle, courteous, friendly, attentive, and caring! You have to develop a step-by-step practical template that helps make the utmost of your limited available time and resources efficiently. You have no choice. You have no time to figure it out during the interview. No way! You will be nervous, irritable and thoughtless! And the patient, playing his role comfortably, enjoys watching you making lethal mistakes! Do not get me wrong. They are not bad guys. Their role is to stress you out to assess your performance. Sounds like you in an OSCE, right. You need a template that you will follow with every patient with the same group of illness every time automatically even if you are mentally exhausted or irritable. You need something to keep you organized and provide you with a road map to follow safely towards your goal of solving the station. You have to be prepared. There is no time to think in the OSCEs. You need a step by step system that makes you perform fast and yet makes you look calm, attentive, listening, and in control. A guide that makes you focused on the patient current situation and yet thorough exploring hidden issues like abuse or denial. You will follow the same steps with every patient. You’ll even repeat the same questions and sentences. Even the same reactions and empathy! In each OSCE room, there is a new patient (and a new examiner, if applicable). They didn’t watch your performance in neither the previous stations nor they will in the following ones. Just repeat! Simple! This book is about this third aspect. You don’t need to develop a template. My colleagues and I did it for you. You just have to memorize the steps and sentences as it is, practice it, then practice it again, and finally practice it until you perform the steps and say the sentences in an autopilot mode!. 23.

(24) The Medical Interview: Notes Medical knowledge and differential diagnosis has been covered in these steps. Verbal communications and ethical issues are also covered. You don’t need to add anything else concerning the medical interview. However, this book does not cover the post encounter questions, write ups, or non verbal communication skills. Visit www.oscehome.com for other resources concerning these issues.. 24.

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(27) PART TWO THE HISTORY TAKING INTERVIEW. 27.

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(29) Chapter 6:. THE HISTORY TAKING INTERVIEW. The MODEL To be organized, thorough, and not to forget important points, in the 5-20 minutes medical interview, you will follow the following steps IN SEQUENCE:. 123456-. The Minute(s) Before the interview. The Introduction box. The Initial History Taking box. Station appropriate questions box. Standard questions box. Wrapping up box.. Use every possible opportunity while going through these boxes to develop a relationship with the patient. You should go through each of these steps in sequence while budgeting your time. I’ll explain each step in detail latter. But here are some tips. Read all of part two once without memorizing it in order to have an idea about how this model is organized. Then read it chapter by chapter. Stop at the end of each chapter. Memorize it. Practice, practice, and practice that chapter until you feel happy with your performance. Now, move to the next chapter. And repeat the same. As you read through the chapters, you may feel that it is impossible to finish all the steps in 5-20 minutes. There are so many questions to ask. The answer is in fact, no, it is not impossible and you can do it! … How? First, when you memorize the questions and practice them over and over, it won’t take long to ask. Remember, you are on autopilot. Secondly, you are going to ask only the screening question. Only if the patient’s reply was positive, you will explore further asking ALL the detailed questions. Third, the patient’s answer will be negative for all screening questions but one or two to be explored. The shorter the station the less positive answers will be. That is how the OSCE is organized. But don’t skip questions or steps. There are check marks that you don’t want to miss! 29.

(30) The History Taking Interview: The Model How long does it take to ask a one sentence carefully phrased question with a ‘no’ answer? … Less than five seconds! That’s 10-12 questions per a minute in an autopilot mode! Try it. But be careful, be relaxed friendly, attentive, interactive, and engage the patient. Don’t interrupt the patient or rush him/her. Don’t overwhelm the patient with rapid sequence firing questions. When you eliminate the burden of what to ask now and next. When you don’t have to think about ‘how’ to ask about something in a medically and ethically correct manner. When you are in control of the interview. Then, you’ll have time to think about solving the station. You’ll have time for communication skills and empathy. You’ll feel confident and will reflect that on your performance. Although you don’t have to, but studying your medical knowledge along with each system you practice here will show you the logic of these questions and how are they covering the main possible differential diagnosis. This may make them easier to memorize and remember. You don’t need to do that at the beginning. For example, study history taking, physical examination, differential diagnosis, risk factors, investigations, and management plans of chest symptoms and signs all together. This will cover respiratory, cardiac, upper gastrointestinal, and musculoskeletal systems at least. Master them then move on to another body part or system, and so on. Keep yourself focused on symptom-oriented approach. Find answers to required questions covering each topic. When you practice, don’t explain to yourself or memorize what you will do in the OSCE. This is a recipe for failure. Never do that. Practice by real acting. Imagine yourself in that OSCE exam room talking to the patient. Act as a professional actor. Act in every detail. Train yourself into an autopilot mode. One more thing before you begin. As you reach your last few practice trials for each section, make yourself unconsciously oriented to time. There is no clock in the exam room and it is completely wrong to look on your watch during the medical encounter. This will sent a non verbal message of being not interested. Make a habit of how long it takes to do things in your life other than medicine. For example, it takes you three minutes to shave, or five minutes to wear make up, or five minutes to fry an egg, and so on. Live these minutes and make road marks for yourself. For example, by the time you finish shaving the right side of your face, only two minutes left. Did you get what I mean? You do things in your life every day in a step by step manner! And you do them repeatedly with the same amount of time! Make your OSCE performance the same, a step by step manner for the same amount of time. Practice, Practice, Practice.. 30.

(31) The Medical Interview Model© Minute(s) Before the interview Introduction Box Initial History Taking Box Station Appropriate Questions Boxes (one or two of:) Respirology. Cardiovascular. Gastrointestinal. Endocrinology. Genitourinary. Neurology. Musculoskeletal. Dermatology. Obstetric/Gynae. Pediatric. Psychiatry. Standard Questions Box A Step By Step To Mastering The OSCEs MedInfo Consulting © 2006. Wrapping up Box 31.

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(33) Chapter 7:. THE MINUTE(S) BEFORE THE INTERVIEW. Ten steps to perform in these one or two minutes before the medical encounter:. 1- Have a new blank sheet on your clipboard/ booklet. 2- Put your sticker(s) on your left hand index finger (or on your answer sheet). 3- Write down: Patient’s name (if a child; also; accompanying person’s name and his/her relation). 4- Write down: Patient age. 5- What is the setting?: Use abbreviation, such us - Your office? write OFF; - Walk-in clinic? write WC; - Covering a colleague? write CC; - Emergency Room? write ER. 6- Identify the station type: Use abbreviation, such us - History Taking?  write Hx; - Physical Examination?  write PE; - Consult?  write CON; - Combination?  write Hx & PE, Hx & CON - Emergency?  write ER. Then which ER type: - Management?  write MANAGE. - Post acute phase/ after management by others and stable now?  write Consult. - Any of the above: Hx, PE, Hx and PE. 7- Identify the Chief Complaint (CC) / Consult subject and duration if given write it down. 8- Write down any given findings (Circumstances, vitals or labs). 9- Identify the CC body system(s)? write it down. 10- Remember the station(s) appropriate questions box and differential diagnosis (DDx).. On the whistle/ buzzer/ bell: Knock the door and go in smiling, calm with shoulders up. (Show confidence and friendliness). 33.

(34) The History Taking Interview: The Minute(s) Before. TIPS:. 34. -. Practice this step.. -. Memorize the ten steps in sequence.. -. Get blank papers and a clipboard or a pocket booklet just like the one you use in the exam. Check your exam official site to know what kind of papers will be given in the exam.. -. Find a door at your home leading to a small room. Any door.. -. Wear a lab coat and decide where are you going to put your pencil, stickers, stethoscope, pen light, hammer, measuring tape, the notebook and any other instruments asked to bring with you. Select places according to your connivance and rapid access.. -. Practice to take out these tools use them and put them back at the SAME place you decided to do. This is very important. As in exams, you will be nervous and you will forget where are these tools and will start looking for them nervously wasting valuable time and showing the examiner and the patient that you are not organized and don’t know what to do next!. -. Take the blank papers and decide how are you going to organize it. Where to write the eight required information like the name, age, station type, etc. It is important to stick to the same format for quick access.. -. It is very important to write every thing as you will be amazed how quickly you will forget them during the encounter due to the exam’s fast pace and nervousness.. -. Place a peace of paper on the door with a stem question written on it. Get stem questions at OSCEs Home at http://www.oscehome.com.. -. Practice the ten steps over and over and over until you feel you are doing them naturally and confidently.. -. Don’t worry about how long it takes to do it at the beginning. Just master the steps first. Then, with time try to be faster and faster to finish it with ONE minute.. -. After you master it. Do it in front of family members or study group. Ask them to criticize you honestly and freely. Ask them about your nonverbal communication, gestures, standing position, head position and look Accept critics openly and adopt changes. Check OSCEs Home communication skill page at http://www.oscehome.com/Communication-Skills.html.. -. Practice and practice and practice. Never underestimate the importance of acting and living the steps. Don’t tell yourself that you will do so and so, DO IT. Just do it. You can do it !.

(35) Chapter 8:. THE SELF-INTRODUCTION. Ten steps to perform in this stage of the medical encounter in 15 seconds: 1-. Give the examiner your sticker, smile and move on (if applicable).. 2-. Approach the patient while smiling and relaxed.. 3-. Identify the patient: “Mr/Ms…..?” in a questionable tone.. 4-. Establish a sense of privacy: Draw a curtain / close the door / suggest that a visitor wait outside (Accept the patient decision).. 5-. Introduce yourself confidently, softly, friendly, comfortably: “Hi, I am Dr …….… (last name)”. Shake hands, if you want (Preferred).. 6-. Mention your position: one of: - in your office: nothing more. - in a colleague clinic: “I am covering for Dr….today”. - in a walk in clinic / ER: “I am the physician on duty here today”.. 7-. Ask the patient about how he/she would like to be addressed: “Mr/Ms….., how would you like me to address you?”. 8-. Quickly screen the room: Where is the patient, your chair, stretcher, and TOOLS. Tools in the room are more likely meant to be used.. 9-. Ask the patient to sit down (pointing where) if he/she is not already sitting or lying on a stretcher. “Be seated/ lie down (if needed) here please.”. 10- Then sit down. Don’t move the chair closer to or away from the patient. Ideally about a meter far and in a narrow angle.. Through out the medical encounter: -. -. Maintain an attentive position: leaning forward 10 % with straight head, back and shoulders up. Maintain eye contact almost throughout the interview. Look at the patient’s forehead at the mid line just above the nose. The patient will think you are looking on his/her eyes, which is a sign of interest in him/her. Looking at the patient’s eyes will disturb your thinking. Avoid that. Minimize distractions, including writing down notes. Give the patient the time to answer in his/her own words, then facilitate and clarify.. Note: Hereafter in this book, sentences addressed to the patient will be in blue color and starts with “Mr/Ms…,” and placed between quotes. However, you don’t have to say Mr/Ms. Choose what the patient decided to be addressed with for at least three times during the interview. Not with every question. 35.

(36) The History Taking Interview: The Self-Introduction. Sentences to be memorized in sequence: 1. “Mr/Ms…..?” in a questionable tone. 2. “Hi, I am Dr …….… (last name)”. 3. Nothing or “I am covering for Dr….today” or “I am the physician on duty here today”. 4. “Mr/Ms….., how would you like me to address you?” 5. Nothing or “Be seated please.”. TIPS:. 36. -. Practice this step.. -. Memorize the ten steps in sequence.. -. Imagine the patient is setting on your right (and the examiner on the left) and practice. Now change positions and practice. Imagine the patient is lying down on a stretcher on your right, then left, then in front.. -. Practice the ten steps over and over and over until you feel you are doing them naturally and confidently.. -. Don’t worry about how long it takes to do it at the beginning. Just master the steps first. Then, with time try to be faster and faster to finish it with 15 SECONDS or less.. -. After you master it. Do it in front of family members or study group. Ask them to criticize you honestly and freely. Ask them about your nonverbal communication, voice tone, gestures, eyes and eyebrows movements, lips movements, standing position, head position and look. -. Accept critics openly and adopt changes. Check OSCEs Home communication skill page at http://www.oscehome.com/CommunicationSkills.html.. -. Practice and practice and practice. Never underestimate the importance of acting and living the steps. Don’t tell yourself that you will do so and so, DO IT. Just do it.. -. You can do it !.

(37) Chapter 9:. THE CHIEF COMPLAINT. 10 steps to be done in ONE minute: 1- “Mr./Ms… I’ll be writing down some notes while we talk,.. okay?” 2- Clarifying the Chief Complaint (CC): “I understand, you have been having some…. (CC from the stem question) ”(best sentence) or “How can I help you?” or “What brings you here today?”. 3- Write down the CC in patient’s words. 4- Make sure what is the real CC: “So, you have …(CC), …. Let’s talk about it, but first, is there anything else bothering you? Are you having any other problems physically? Or, are there any special stresses in your life right now?.” If yes  “Which one do you want us to discuss first/today?” 5- Invite him/her to tell their story “Tell me all about the …(CC) right from the beginning ”. 6- Maintain eye contact, don’t interrupt, facilitate and encourage with sounds (Ah ha, yes, go on, I see), head nodding, and empathy facial gestures. 7- When he/she stops, explore the CC if he/she uses vague terms like tired, dizzy, diarrhea .etc,  “What do you mean by…....?” Offer menu list of 2-3 descriptions. 8- Duration: “When would you say it started?”  make sure “So it started .… ago?”. 9- If CC presents for some time: “What made you decide to get it checked now?” 10- Empathy: Watch your voice tone and facial expressions. Reasons to come now are: 1. Symptoms worsen. 2. Anxiety developed, even if symptoms lessen. 3. An excuse for a hidden CC.. “That must be very difficult for you to cope with?” “I can see you have been under a lot of stress” “How are you feeling about that?” Patient’s non-verbal “How has this been affecting you?” cues of distress: - Avoiding eye contact. “I can see you are/ It sounds like you’re feeling / - Fidgeting. You seem (anxious/ worried/ angry/ upset/ - Shifting around in the frightened) …….. Is that right?” chair. “This is completely understandable. Most people - Holding their body tensely. in similar circumstances would react just as you However, don’t assume are.” that, check it out with “I am sorry to hear that.” them. (? Cultural). “It must be hard for you, what are you unable to do as a result of the …(CC)” “It would be surprising if you didn’t feel (angry / upset / worried / frightened) after hearing that / waiting all that time.” “This can’t be an easy time for you, we’ll work together to get through this.”. Silent or Talkative patient? How to save time and direct the patient? Find out how at the book: “How To Unlock Difficult Patient Encounters”. www.oscehome. com/DifficultOSCEsSenarios.html. 37.

(38) The History Taking Interview: The Chief Complaint If the patient asked: “Is it serious?” “Am I going to die?” “Do I have..(cancer, heart attack)?” “Do you think that … (my medications/ work/ doctor/ partner….etc) is causing the ..(CC)”  Reply: “Mr/Ms…, I can see you are anxious and I am glad you came here today. We need to look on certain things and run some investigation to be sure. Relax for now, together, we’re going to figure it out” No false information or hope but also no worrisome comments. Keep it neutral and open to both good and bad outcomes!. Sentences to be memorized in sequence: 1. “Mr./Ms… I’ll be writing down some notes while we talk,.. okay?” 2. “I understand, you have been having some…. (CC from the stem question)” or “How can I help you?” or “What brings you here today?”. 3. “So, you have …(CC), …. Let’s talk about it, but first, is there anything else bothering you? Are you having any other problems physically? Or are there any special stresses in your life right now?.”.  “Which one do you want us to discuss first/today?” 4. “Tell me all about the …(CC) right from the beginning ”. 5. “When would you say it started?”  “So it started .… ago?”  “What made you decide to get it checked now?” 6. Empathy sentences: Very important.. TIPS:. 38. -. Memorize the ten steps in sequence.. -. Practice the ten steps over and over and over until you feel you are doing them naturally and confidently.. -. Don’t worry about how long it takes to do it at the beginning. Just master the steps first. Then, with time try to be faster and faster to finish it with ONE MINUTE or less.. -. After you master it. Do it in front of family members or study group. Ask them to criticize you honestly and freely. Ask them about your nonverbal communication, voice tone, gestures, eyes and eyebrows movements, lips movements, standing position, head position and look. -. Accept critics openly and adopt changes. Check OSCEs Home communication skill page at http://www.oscehome.com/CommunicationSkills.html..

(39) Chapter 10:. History of Present Illness (HPI) OSCD PQRST UVW + AAA. The following 15 points has to be explored ALL for pain CC. It should also be used to explore any other CC, e.g. vaginal bleeding, cough, shortness of breath, dizziness, vomiting, diarrhea, hematuria ..etc, except place, radiation and quality (5, 6, 7) which will be explored in the station appropriate boxes. 1) Onset: “How did it start? Was it all of a sudden or gradually?”. 2) Setting: “What were you doing when it started?”. 3) Course: “Is it getting worse, better or just the same?”. 4) Duration: “You said it started … ago, does it come and go?” If yes  “How often / frequent does it come?”….. “For how long dose it stay each time?”. 5) Place: “Show me exactly where is it on your body, point where with one finger”. Only for pain CC. 6) Quality: “Tell me, how does it feel like?”……   Clarify one at a time: Is it sharp? Stabbing? Dull? Tight? Cramps? Squeezing? Burning? ” 7) Radiation: “Does it go/ shoot anywhere?”. 8) Severity: “How bad is it, on a scale from 1 to 10, with 1 is the mildest, and 10 is the worst pain?,… Does it interfere with your daily activities?”. 9) Timing: “Is it worst in a particular time of the day?”. 10) U (you) Your daily activities: “Does it change with your daily activities like posture, exertion, rest, sleeping, eating, hunger?”. 11) V (déjà vu): “Has it happened before?” If yes  “When?… How did you handle it?…What happened to it? … Which doctor?… What medication? ..etc Explore. 12) What: “What has worked for you so far?... What hasn’t?… What do you think is causing it?…” 13) Aggravating factors: “What brings it on? What makes it worse?” 14) Alleviating factor: “What makes it better?” 15) Associated symptoms: “Have you noticed anything else that occurs with it?” If the patient ask “What do you mean/ such us what?” “Any thing that you may recall?”.. 39.

(40) The History Taking Interview: History of Present Illness (HPI). Summarize:. Important “Let me see if I have it straight. You felt perfectly well until …. ago when you felt….(CC)?.. The….(CC)………”. Interviewing technique:  Start with: General open-ended questions.  Then: Topical open-ended questions.  Proceed to: Lists / Menus questions.  Then: closed-ended questions.  Then: Yes/ No questions.  Use minimal facilitators: “ Yes, uh huh, head nodding, what else?, .. and?.”  Avoid: - Leading questions. - Multiple questions at the same time.. Sentences to be memorized in sequence: “How did it start? Was it all of a sudden or gradually?”. “What were you doing when it started?”. “Is it getting worse, better or just the same?” “You said it started … ago, does it come and go?” If yes  “How often / frequent does it come?”….. “For how long dose it stay each time?”. 5. “Show me exactly where is it on your body, point where with one finger”. 6. “Tell me, how does it feel like?….. Is it sharp? Stabbing? Dull? Tight? Cramps? Squeezing? Burning? ”. 7. “Does it go/ shoot anywhere?” 8. “How bad is it, on a scale from 1 to 10, with 1 is the mildest, and 10 is the worst pain?,… Does it interfere with your daily activities?”. 9. “Is it worst in a particular time of the day?”. 10. “Does it change with your daily activities like posture, exertion, rest, sleeping, eating, hunger?”. 11. “Has it happened before?” If yes  “When?… How did you handle it?…What happened to it? … Which doctor?… What medication? ..etc Explore. 12. “What has worked for you so far?... What hasn’t?… What do you think is causing it?…”. 13. “What brings it on? What makes it worse?”. 14. “What makes it better?”. 15. “Have you noticed anything else that occurs with it?”“Any thing that you may recall?” 1. 2. 3. 4.. Before you proceed. Make sure that you did memorize and practiced these steps first. Make sure that you have been doing them confidently and naturally. You must be able to finish them in about 2 - 2.5 minutes fluently & comfortably!. 40. TIPS: -. -. Memorize the 15 steps in sequence. Don’t worry about how long it takes to do it at the beginning. Then, with time try to be faster and faster to finish it with ONE MINUTE or less..

(41) Chapter 11:. THE STATION APPROPRIATE QUESTION BOXES. This includes symptoms and risk factors associated with the CC organ system. Use only one or two of these station appropriate question boxes at each OSCE station. Decide which one and remember the questions during the “Minute(s) Before” step. Now, as we reached this stage, you must use a transitional statement to prepare the patient to the next stage in the interview and to appear organized. You don’t have to pause. Just after you finished a quick summary of the previous step, the chief complaint, tell the following transitional sentence: “Mr/Ms..., now, I want to ask you some questions about things that may or may not be associated with ....(CC), okay? ” This will show your organizational skill and prepare the patient to what are you both doing next in a respectful way. Many patients will appreciate having road maps about what is going during the medical interview and most importantly WHY you are asking these questions and why should they answer them. This will avoid having the patient jumping in your face with a questioning comments like:. Systems are: Neurology, Respiratory, Cardiovascular, Gastrointestinal, Genitourinary, Dermatology, Endocrinology/ Hematology, Musculoskeletal, Obstetrics & Gynaecology, Pediatrics, and Psychiatry.. “Why are you asking this?… Is this relevant?… Do I have to answer that? … Do you thing that’s what’s causing it?, .. etc.” Standardized patients in OSCEs are trained to do so and they love to do it! So, attempt to cut the possibilities of letting them ask you so by using short informative sentences to justify what are you going to ask and prepare them. In each box, there are several SCREENING (underlined) questions. You will ask only these questions. Screening questions are also used for the system review questions. If the patient replies with positive answer for any screening question, then you will explore that symptom with further EXPLORING questions. Exploring question covers all the differential diagnosis for that symptom (even if you don’t know it). Never ask exploring questions if the patient’s answer was negative. Some of these questions may already been asked during the HPI if they are relevant to the chief complaint, use them to explore it. Don’t repeat… Confused?… Don’t worry now!… With practice you will remember these detailed questions while taking the HPI. Questions formats: “Do you have .../ Does he/she have…/ Have you .../ Has he/she …/ What about .../ In what way…?” If yes for anyone explore. NEVER USE NEGATIVE QUESTION, like “And you don’t have ..…(fever) ”. They are leading questions. You are giving the patient the impression that you want a negative answer for this question!. 41.

(42) The History Taking Interview: Station Appropriate Question Box: NEUROLOGY. Neurology appropriate questions: HLD NeW VHS MTC 1- H eadache: “Do you have headache?” Screening question. Yes  Explore: OSCD PQRST UVW AAA - Onset: “How did it start?” (thunderclap in Subarachnoid hemorrhage). - Place: “Show me exactly where is it on your head, point where with one finger… Is it on one side or both?”. - Severity: …“Does it interfere with your routine physical activity and work?” - Timing: “Is it worse in a particular time of the day?”( AM: ICP/ PM: Tension, migraine), - U: Does it change with your daily activities like posture (lying down/sitting), eating, hunger, exertion, rest, sleeping/ wakes you up (Cluster))? - Associated symptoms: “Have you noticed anything else that occurs with it?.. feeling sick (nausea) or throwing up (vomiting)?…/ Stiff neck?.../ Eye problems?…./ Pain on chewing?…/ Annoyed by light?”, Warning signs: “Is it preceded by warning signs?… What are they?” (aura in migraine).. 2- Loss of Consciousness(LOC): “Have you passed out / blacked out?” Yes  Explore: OSCD PQRST UVW AAA. Seizure or syncope. - Empathy: “Ooooh, did you hurt yourself?” - Duration: “For how long did that last?” - Completely: “Did you lose consciousness completely or could voices be heard?” - Body Position: “What was your position during the attack?” - Body Movements: “Did any body movements occur?” - Tongue-biting: “Did any tongue-biting occur?” - Confusion/ sleepiness after attack: “How did you feel after the attack?” - Urinary/ bowel Control: “Was there any loss in bladder or bowel control?”  Seizures: “At what age did it start? How often dose it happen?” - Warning signs: “Was it preceded by warning signs?.. such us lightheadedness? ”. 3- D izziness: “Have you felt unsteadiness (vertigo) or light-headedness (presyncope) ?”. Yes  Explore: OSCD PQRST UVW AAA. - Duration: “For how long?” - U: “Does it change with your head movement?.. Opening or closing your eyes?.. How?” (: Vestibular),.. Does it only occur for a minute in certain head positions? (BPV, VBI),.. Does it change with exercise? (Cardiopulmonary)” - Associated symptoms: “Have you noticed anything else that occurs with it? ... Feeling sick (nausea) or throwing up (vomiting) ?…/or hearing change?(Inner ear disease),... Gait problem? (Ataxia),.. Double vision?, Difficulty speaking? (Brainstem disease) ”. …. Continued 42.

(43) The History Taking Interview: Station Appropriate Question Box: NEUROLOGY. Neurology appropriate questions, …Cont 4- Numbness: “Do you have numbness, loss of sensation, or pain anywhere?” Yes  Explore: OSCD PQRST UVW AAA - Place: Where?.. One side or both?” Is it localized to a dermatome? - Quality: “Does it feel like tingling?… prickling?…. warm?…. cold?. pressure?.... Or like a distorted sensation in response to a stimulus?”. 5- Weakness: “Any weakness?” Yes  Explore: OSCD PQRST UVW AAA - Place: “Where?…. One side or both?”…. “What activities do you have difficulty with?” Proximal (standing/combing): (myopathy)/ or distal (neuropathy).. 6- Visual changes: “Any visual changes recently?” Yes  “In what way?.. One eye or both?.. Any eye pain?.. Tearing? Redness?,.. Does light bother you?,.. Double vision?.. vertically or horizontally?.. Any flashing lights?”. 7- Hearing changes: “Any hearing changes?.. Yes  “Do you hear any noises or tinnitus in your ears?…. Earache?… Ear fullness?… Any ear discharge?” Yes, How much, what colour is it?… Is it thin or thick?.. How dose it smell?.. Any blood?”. 8- Difficulty Speaking: “Do you have difficulty speaking?” Yes  “In what way?”.. 9- Memory/Concentration: “Have you noticed any memory loss/ difficulty concentrating?” Yes  “In what way? ”.. 10- Tremor: “Any tremor or involuntary movements?. Yes  “In what way?…. Is it worse with certain postures (Essential postural), movement (Intentional: Cerebellar) or rest (Parkinson) ?” “Any gait problems?””.. 11- Bladder / Bowel C ontrol: “Do you control your bladder and bowel motion?” No  “In what way?”.. 43.

(44) The History Taking Interview: Station Appropriate Question Box: RESPIRATORY. Respiratory appropriate questions:. PCS Wheezes HEAT On Us + Risks. 1- Chest Pain: “Any chest pain?” Dry cough: Viral, Interstitial, Allergy, Cancer.. Productive cough: Bronchitis, Bacterial pneumonia, Abscess Bronchiectasis, TB.. Uninfected sputum: Mucoid, transparent, odourless, whitish gray.. Purulent rusty: Pneumococcal pneumoni. Red current jelly: Klebsiella pneumonia. Foul smell: Abscess Frothy pink: Pulmonary edema. Positional: Abscess, Tumor, GERD. Hemoptasis: with cough & dyspnea; red; frothy; may be with pus.. Hematamesis: with nausea & vomiting; red/brown; not frothy; may be with food.. SOB with exercise: Chronic bronchitis / emphysema, CHF.. SOB at rest: Asthma.. Yes  Explore: OSCD PQRST UVW AAA - Duration: “You said it started … ago (<2 months: unstable angina?) , does it come and go?.. How long dose it take to go away?.. So, it is more (ischemia) / less (angina) than 15 minutes?” - Place: “Show me exactly where is it on your body, one side or both?” - Quality: “Tell me, how does it feel like?. Is it sharp or aching pain?.” - Timing: “How frequent does it come in a day? (>3/d: severe)” - U: Is it worse with deep breathing or cough (Pleuritic)?.. position change (MSK)?.. eating (Esophageal spasm)?” Sharp, one side, worse with deep breathing or cough  Pleuritic. Aching, one side, lateral low down  Spontaneous pneumothorax.. 2- C ough: “Do you have cough?”. Yes  Explore: OSCD PQRST UVW AAA - Duration: “You said it started … ago, does it come and go?” If yes  “For how long it dose stay each time?” Acute vs. chronic (>3 months for 2 years).. - Place: “Do you feel it coming from something in your throat or deep in your chest? ” - Quality: “Is it dry or with sputum / phlegm? Yes  - Sputum: “How much sputum would you say?… A cup a day?.. Is it thin or thick?.. What colour is it?.. How does it smell?” - Blood: “Do you cough up blood?” Yes  Fresh blood or altered? How much blood? How frequent do you cough up blood?” - Timing: “Is it worst in a particular time of the day or season?”, “How often does it come?” (Morning: smoking, Nocturnal: Postnasal drip, CHF, asthma.).. - AAA: “What brings it on? What makes it worse?” “Is it worse with dust?.. Pollen?.. Cold air?.. Pets? (Asthma)..Position? (GERD).”. 3- SOB : “Do you get shortness of breath? ” Yes  Explore: OSCD PQRST UVW AAA - Onset: “How did it start? Was it all of a sudden or gradually (PE)?” - Setting: “What were you doing when it started (Dusting/ Exercise)?” - Quality: “How does it feel like?.. Is it like air hunger, suffocation, or heavy breathing (cardiac) ?,…. Is it like rapid shallow breathing? (chest wall), Chest tightness? (Asthma), .. Increased breathing effort? (COPD/ ILS) ” - Severity: “How frequent?... How many times a week?…” “When you get shortness of breath, are you able to speak?,… Got blue?,… Felt tired to breath?,… Blacked out?,.. Sweating?” ….Continued. 44.

(45) The History Taking Interview: Station Appropriate Question Box: RESPIRATORY. Respiratory appropriate questions:. …Cont. - “Any visits to the emergency in the last 12 months?” Yes  “How many times?... Have you ever had a breathing tube down your throat or been on a breathing machine?… Have you ever been admitted to the hospital?,… Intensive care unit?” - Timing: “Is it worst in a particular time of the day or season?.. Is it worse at night? (asthma)” - ADL: “What activities are you no more able to do?” Empathy. - U: “Is it related to exercise?.. Is it relieved by rest?” - Orthopnea: “Are you able to lie flat in bed without becoming short of breath?.. How many pillows do you sleep on at night?”(asthma>COPD) Do you sometimes wake up gasping for air? (Sleep apnea / Paroxysmal nocturnal dyspnea in HF)”. 4- Wheezes: “Do you hear noises in your chest with breathing?.. What about in your throat?”(Stridor?). 5- H oarseness: “Any change of voice?” 6- Exercise intolerance: “How many flights of stairs can you climb/ blocks can you walk?.. So, it is more (grade II)/ less (grade III) than two blocks/ one flight?”.. 7- A nkle swelling: “Do your ankles swell on you?”(edema?) , Yes: When did it start?.. How long did it take to go away?”…. “Any pain in your legs?”(DVT.. PE?).. 8- Travel: “Any history of travel?.. Where? ”(exposure to TB, SARS, HIV). 9- O ccupation: “What do you do for living?.. Does your ..(CC).. improve during weekends or vacations?”.. “What exactly does this job involve?”. 10- Others: “Any exposure to people with HIV, TB, SARS?”.. “Have you ever felt your heart racing?,.. Any face flushing?.. Any diarrhea” (Hormone secreting tumors).. 11- URT: “ Any running nose?.. Eye problem?.. Skin rash (Viral) ? Face pain? (Sinusitis),.... Do you need to clear your throat frequently? (Post nasal drip)”. 12- Risk factors: Will be asked in the standard questions box: Smoking (+2nd hand), Cold, Travel, Allergies, Pets/ dust, Occupation, HIV/TB, emotional changes, medications (ASA, ACEI, Beta blockers).. 45.

(46) The History Taking Interview: Station Appropriate Question Box: CARDIOLOGY. Cardiology appropriate questions:. PCS OSAP PLC EAR. 1- Chest Pain: “Any chest pain?” Yes  Explore: OSCD PQRST UVW AAA - Duration: “You said it started … ago (<2 months: unstable angina?) , does it come and go?.. How long it takes to go away?.. so, it is more (ischemia) / less (angina) than 15 minutes?” - Place: “Show me exactly where is it on your body, one side or both?” - Quality: “Tell me, how does it feel like?. Is it sharp or aching pain?.” - Timing: “How frequent does it come in a day? (>3/d: severe)” - U: Is it worse with deep breathing or cough (Pleuritic)?.. position change (MSK)?.. eating (Esophageal spasm)?”. 2- Cough: “Do you have cough?”. Yes  Explore: OSCD PQRST UVW AAA - Duration: “You said it started … ago, does it come and go?” If yes  “For how long dose it stay each time? ” Acute vs. chronic (>3 months for 2 years).. - Place: “Do you feel it coming from something in your throat or deep in your chest? ” - Quality: “Is it dry or with sputum / phlegm? Yes  - Sputum: “How much sputum would you say?… A cup a day?.. Is it thin or thick?.. What colour is it?.. How does it smell?” - Blood: “Do you cough up blood?” Yes  Fresh blood or altered? How much blood? How frequent do you cough up blood?” - Timing: “Is it worst in a particular time of the day or season?”, “How often does it come?” (Morning: smoking, Nocturnal: Postnasal drip, CHF, asthma.).. - AAA: “What brings it on? What makes it worse?” “Is it worse with dust?.. Pollen?.. Cold air?.. Pets? (Asthma)..Position? (GERD).”. 3- SOB : “Do you get shortness of breath? ” Yes  Explore: OSCD PQRST UVW AAA - Onset: “How did it start? Was it all of a sudden or gradually (PE)?” - Setting: “What were you doing when it started (Dusting/ Exercise)?” - Quality: “How does it feel like?.. Is it like air hunger, suffocation, or heavy breathing (cardiac) ?,…. Is it like rapid shallow breathing? (chest wall), Chest tightness? (Asthma), .. Increased breathing effort? (COPD/ ILS) ” - Severity: “How frequent?... How many times a week?…” “When you get shortness of breath, are you able to speak?,… Got blue?,… Felt tired to breath?,… Blacked out?,.. Sweating?” ….Continued. 46.

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