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OSCE NOTES

Medical History Station

Presenting complaint: what seems to be the problem?

History of presenting complaint

 Onset: when did it start


 Pain, precipitating factors
 Quality, quantity of the symptoms: what kind of symptoms are you suffering from and
how much of it?
 Radiation, relieving factors
 Severity/score, other symptoms: on a scale of 1 to 10 how severe is the pain; do you
experience any other symptoms?
 Timing: how often do you experience these symptoms; do you experience them
continuously or not?
 U ‘YOU’: is there anything that you are concerned about?

Past Medical History: Have you ever had any previous medical problems?

Drug history

 Are you on any current medications? [prescribed (by who), over the counter, herbal]
 Are you on any recreational/illicit drugs?
 Have you recently started or stopped any medications? Since when and why?
 Allergies: are you allergic to anything?

Family history

 Do any of your family members suffer / suffered from any medical conditions?
 Are both of your parents alive and well? And if someone died, did they die from any
medical conditions? ( make it appropriate to patient )/

Social history:

 Alcohol (if yes how much and how long?), smoking (if yes how much and how long?),
occupation, stress (do you consider your occupation to be stressful?), exercise, housing,
hobbies, travel (have you recently travelled somewhere?)

System enquiry:

 Cardiac red flags


o Chest pain
o Breathlessness / shortness of breath (dyspnoea): on exertion, lying flat
(orthopnea) (having to sleep up)); does it lead you to wake up at night and how
many pillows do you sleep with to avoid your breathlessness when sleeping?
o Palpitations: do you feel any irregularities in your heart beat?
o Ankle swelling (edema is in both legs)
o Exercise tolerance (how long is your exercise before you get tired or get a rest)
o Pain in legs when walking (intermittent claudication); when poor heart condition,
not enough oxygenated blood reaches the legs and therefore, built up of lactic
acid.
 Gastrointestinal red flags
o Abdominal pain (where is the pain?)
o Nausea / vomiting; is there blood in your vomit
o Altered bowel habit (are there any changes to your bowel habits?) Is there blood
in your stool?
o Heartburn, indigestion (dyspepsia), acid reflux
o Swallowing problems (how painful and difficult is it)
o Unintentional weight loss
 Respiratory red flags
o Cough
o Blood in cough (haemoptysis)
o Sputum: color, viscosity, quantity
o Wheeze (noise during exhaling) and stridor (noise during inhaling)
o Breathlessness / shortness of breath (on exertion, lying flat (orthopnea); does it
lead you to wake up at night and how many pillows do you sleep with to avoid
your breathlessness when sleeping?)
o Chest pain( going to be in a side)

Medication History station

Identity of the patient: Name and identity

Current prescribed medication: name of the drug, strength, dose/frequency, route, duration of
therapy (how long have you been taking it). Are you taking the medication as prescribed?

Other medication: OTC, herbal/vitamins/minerals, recreational, topical preparations, hormone


replacement therapy, injections, patches, contraceptives, etc. Do you get any medications from
any specialist clinics? Do you use compliance aids?

Past medications taken in the past: have you recently taken or previously stopped any
medication? And why?
Hypersensitivity: Allergies?

Adverse reactions: side effects, and how severe are they?

Concordance with therapy: do you adhere to the treatment? Are you taking the medications as
prescribed? Do you remember to take your medication regularly? Dose wise and frequency wise

Responding to symptoms station

Age / appearance

Self or someone else?

Medication that the patient is on: prescribed, OTC, regularly take

Extra medicines: have they taken anything already to treat the symptoms they are suffering from.

Time persisting: How long have you had this symptom?

History

 How the problem began


 Has the problem progressed or have gotten worse?
 Have they had the problem before
 If action was taken in the past; how successful was that?
 Medical history: have you had any medical problems in the past?

Other symptoms: are you experiencing any other symptoms than the ones you came today for?

Danger symptoms: refer to all red flags mentioned above

The patient should be advised to get referred or to be treated in the pharmacy.

Sore throat referral point:

 Longer than ONE week


 Sign of toxicity to a drug
 Recurrent bouts of infection
 Hoarseness lasting more than 3 weeks
 Difficulty swallowing
 Failed medication

Cough and Cold referral point:

 Cough lasting more than two weeks and worsening


 Chest pain
 Shortness of breath
 Wheezing
 Blood in sputum
 Yellow/green/rust coloured sputum
 Recurrent nocturnal cough
 Persistent fever and productive cough

Heartburn / indigestion referral point:

 Pain radiating to arms


 Difficulty swallowing
 Regurgitation
 Not relieved by OTC antacids
 Increased severity
 Patients aged over 55 with recent onset persistent dyspepsia
 Recurrent or persistent symptoms
 Severe pain
 Blood in stools/vomit
 Pain worse on exertion
 Vomiting
 Associated with weight loss
 Associated with medication i.e. NSAIDs

Diarrhoea

 Child less than 12 months – lasts >1 day


 Child under 3yrs lasts >2 days
 Older children and adults lasts > 3 days
 Accompanied with severe vomiting/fever
 Blood or mucus in stools
 Suspected medication as a cause
 History of change in bowel habit
 History of travel abroad

General referral points


 Long duration of symptoms
 Recurring or worsening symptoms
 Severe pain
 Failed medication
 Suspected adverse drug reaction
 Danger symptoms