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Phase 4 OSCE > OSCE Histories > Flashcards

OSCE Histories Flashcards

1
Q

General Cardiac Hx

A

HPC
Cardiac Sx
Prev similar episodes

PMHx
HTN, AF, high cholesterol, anaemia, DM, angina, MI, surgery, stroke/TIA, PVD, HF
Dental surgery

DHx
Antihypertensives, cardiac drugs …

SHx
Occupation
Smoking
Alcohol
Diet
Stress
ADL, home independence
IVDU

FHx
IHD <55yo, stroke/TIA before 65yo

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2
Q

Cardiac Sx

A

Chest pain
Palpitations
SOB
Orthopnoea
PND
Ankle/leg/back oedema
Cough, sputum, blood
Dizzy
Light-headed / faint / LOC
N+V
Claudication

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3
Q

Chest Pain Hx

A

HPC
SOCRATES
Previous episodes
CV / Resp sx
Systemic sx

RFs for MI
FHx, HTN, DM, smoking, high cholesterol, previous heart disease, diet

RFs for DVT
Recent surgery, immobility, malignancy, pregnancy, flight, Hx of VTE

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4
Q

SOB (Resp/CV) Hx

A

Onset, baseline

Timing / variability

Exacerbating / alleviating

Orthopnoea / PND

Cough, sputum, blood, pain, wheeze, night sweats, wt loss, oedema, palpitations

Exercise tolerance - change

PMHx
Asthma, COPD, cardiac disease

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5
Q

Palpitations Hx

A

What do they mean
Provocation / relieving
Onset, duration, frequency
Cardiac / systemic sx
Tap rhythm
Recent anxiety/stress

PMHx
Cardiac problems, HTN, mood

SHx
recreational drug use

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6
Q

Anaemia Hx

A

SOB
Palpitations
Pallor
Fatigue
Faint / dizzy / LOC
Tinnitus

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7
Q

Peripheral oedema (swollen legs) Hx

A

HPC
Onset, duration, site, extent
Pain
Exacerbating / alleviating
Sx progression
Previous episodes / tx
Orthopnoea / PND
CV / systemic sx
VTE RFs
IHD RFs

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8
Q

Fatigue Hx

A

What they mean, constant / episodic, onset, duration

Sleep - hours, quality, snoring/apnoeic

How it affects pt

Neurology, change in bowel habit, flu-like sx, pregnancy sx

Malignancy sx - wt loss, appetite change, night sweats, bone pain

Blood loss - HMB, PR bleed, haematuria, haematemesis, haemoptysis

Anaemia - SOBOE, dizzy…
Hypothyroid - constipation, wt gain, cold intolerance, menorrhagia
Depression - mood, early morning waking
DM - polydipsia, polyuria

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9
Q

General Resp Hx

A

HPC
Resp sx
SOCRATES
DVT RFs
Lumps in neck? (TB / cancer)

PMHx
pneumonia, TB, asthma
Recent dental surgery
Angina
Immunocompromised

DHx
inhalers, steroids, abx, ACEi, amiodarone, BBs, NSAIDs, O2

SHx
Occupation, smoking, pets, travel abroad, living conditions, alcohol, exercise, ADL, independence

FHx
asthma, A1AT deficiency

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10
Q

Resp Sx

A

SOB, exercise tolerance
Orthopnoea
PND
Chest pain
Cough
Sputum
Haemoptysis
Wheeze
Calf swelling / tenderness

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11
Q

Cough Hx

A

Acute / chronic / acute-on-chronic

Onset, timing, duration, variation (diurnal) - when worst in day, keep up at night?

Triggers

Productive
Colour, blood
Consistency
Volume
Odour

Haemoptysis
Definitely coughed up
No of episodes, every time?
Quantity
Consistency - mixed in, liquid, clots
Chest pain, trauma, DVT, SOB, bleeding/bruising elsewhere
Wt loss, fever, night sweats

Travel abroad

Pneumonia / TB contact

PMHx
Asthma, COPD, TB

DHx
Inhalers

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12
Q

Fever Hx

A
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13
Q

Weight loss Hx

A
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14
Q

Night sweats Hx

A
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15
Q

General GI Hx

A

HPC
SOCRATES
GI sx
Urinary sx
Menstrual issues
Systemic sx

PMHx
GI / abdo surgery
Gynae issues
Hx of jaundice, anaemia, diabetes
Gallstones / pancreatitis

DHx
Iron, opiates, NSAIDs, anticoags, SSRIs - GI S/Es

SHx
Alcohol, smoking, occupation, diet, exercise. Recent travel abroad

FHx
IBD, carcinomas, Gilberts,

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16
Q

GI Sx

A

Pain
Jaundice
Weight change

Mouth ulcers
Dysphagia
Dyspepsia
Anorexia / appetite change
Last ate / drank
Nausea
Vomiting
Haematemesis

Abdo distension
Altered bowel habit - diarrhoea/constipation, tenesmus
Blood in stools, melaena
Mucus / slime in stools
Pale stools, dark urine

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17
Q

Abdo Pain Hx

A

SOCRATES
Relationship to food - esp fatty food
GI / systemic sx
Eaten anything unusual
Family member with same sx
LMP, chance of pregnancy

PMHx
Abdo surgery
Groin lumps

DHx
NSAIDs

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18
Q

Vomiting Hx

A

Content
Onset, duration, frequency, timing
Colour, quantity
Triggers?
Related to abdo pain?
Blood - fresh / coffee ground
Eaten anything unusual?
Family with sx?
GI / systemic sx
?Pregnancy
Alcohol
Previous episodes

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19
Q

Dysphagia Hx

A

Onset, duration
Continuous / intermittent
Where does food stick
Solids / liquids / both - which first
Pain
Dyspepsia
Nocturnal coughing / SOB
Lumps in neck
GI / systemic sx
Current oral intake

Cancer RFs
smoking, alcohol, obesity, lack of fruit + veg

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20
Q

Dyspepsia Hx

A

Onset, duration
Describe sensation
After certain food/drink?
Aggravating (position) / relieving
Unusually full / bloated after food?

GI / systemic sx

ALARMS
Anaemia
Loss of weight
Anorexia
Recent onset progressive sx
Melaena / haematemesis
Swallowing difficulty

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21
Q

Jaundice Hx

A

Colour of urine / stools
Colour of eyes
Pain, fever, rigors
Itching
Bruise / bleed easily
GI / systemic sx

Hx of gallstones

SHx - alcohol, drugs, foreign travels (transfusions, tattooing), UPSI

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22
Q

Diarrhoea Hx

A

Onset
Stool frequency, normal habit
Colour, consistency
Float, difficult to flush
Abdo pain - relieved by BO?
Abdo bloating
Incontinence
Constipation prior to diarrhoea
Blood / mucus / melaena
Thyroid sx
GI / systemic sx
Fatigue / SOB (anaemia, colorectal ca)
Family with sx
Foreign travel

FHx
Bowel cancer
IBD

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23
Q

Constipation Hx

A

Onset, duration
Frequency of motions, normal habit
Colour, consistency
Blood / mucus
Abdo pain - relief
Pain on defecation
Strain, tenesmus
Lack of flatulence
Fatigue / SOB (anaemia)
Thyroid sx
GI / systemic sx

FHx
Bowel ca
IBD

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24
Q

Rectal bleeding Hx

A

Onset, no of episodes
Colour
In pan / in stool / on toilet paper / melaena
Volume of blood
Bowel habit change
Slime / mucus
Abdo pain
Painful defecation / straining
Dragging sensation (prolapse)
Lumps / bumps around anus
GI / systemic sx
Urinary sx

DHx
Anticoags

FHx
Bowel cancer
IBD

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25
Weight loss / anorexia Hx
How much weight loss, over how long Loss of appetite? Or deliberate reduction in intake?
26
General Neuro Hx
HPX SOCRATES Neuro Sx PMHx Head / spinal trauma Diabetes, dancer, HTN Epilepsy, AF DHx Anticonvulsants Anticoags Analgesics Antihypternsives, antidepressants, insulin SHx Smoking, alcohol, recreational drugs, occupation, home/ADL FHx Diabetes, stroke, IHD, migraine, epilepsy
27
Neuro Sx
Headache Fits / faints / falls Dizziness / vertigo Weakness Numbness / tingling Changes in vision / double vision Speech, taste, smell Memory loss Anxiety / depression Neck stiffness / photophobia Incontinence Nausea and vomiting
28
Headache Hx
SOCRATES Visual disturbance N+V Weakness, sensation change Recent stress Regular painkillers (misuse) Neuro / systemic sx Colds - sinusitis Previous episodes Bleed Thunderclap headache Trauma Raised ICP Posture related Early morning headache, vomiting Blurred vision Pain worse on coughing Meningism sx Rash Fever Neck stiffness Photophobia GCA sx Visual problems Jaw claudication Scalp tenderness Glaucoma sx Visual blurring Red eye Halos PMHx Polymyalgia rheumatica (linked to GCA)
29
Collapse Hx
Witnessed? Onset, time, what doing at the time Previous episodes LOC? Before General feeling Dizzy, nausea, vertigo, aura, chest pain, palpitations, sweaty, weak, slurred speech, headache Tunnel vision / out like light? During LOC? Duration of LoC Any memory? Movts - floppy / stiff / jerking? Tongue biting, incontinence After Weakness How long until normal Confusion / memory loss Muscle pain Any injuries? Hit head? PMHx Cardiac disease, diabetic (last meal), head injury SHx Driver?
30
Sudden onset weakness Hx
What happened, time course Fall to ground? Hit head? LOC? Pattern of weakness Numbness / paraesthesia Character, eg fatigable Headache, visual disturbance, speech disturbance Previous episodes Neuro / systemic sx Trauma / pain - to limb PMHx CVA RFs - DM, HTN, high cholesterol Arrhythmias, MI, CVA, angina, PVD Previous infections DHx Anticoags SHx Smoker
31
Memory loss Hx
HPC Anterograde / retrograde Neuro sx Head trauma Previous episodes Danger to self / public - eg leaving gas on at home Possible triggers - stress, anxiety, life events Mental health - depression Psych - hallucinations, delusions Systemic sx
32
Delirium tremens Hx
HPC Tremor, fever, insomnia, panic attack, paranoia, hallucination, nausea, low mood, seizures, abdo pain CAGE Alcohol Hx Amount of alcohol drank, type, duration of heavy drinking Previous attempts to stop Tolerance / cravings, FHx
33
General Urological Hx
HPC SOCRATES Uro / systemic sx Previous episodes, tx Sexual Hx Obstetric Hx Gynae Hx PMHx Diabetic, UTIs, DM, gout, HTN, IHD, stroke DHx Meds eg rifampicin Iodine allergy SHx Smoking, alcohol, travel, occupation Diet - beetroot FHx Renal / uro conditions - PKD, DM, HTN
34
Urological Sx
LUTS Haematuria UTI sx Renal calculi - loin / groin pain Uraemia sx - headache, vomiting, fits, drowsy, peripheral oedema
35
LUTS Hx
Filling Frequency, urgency, nocturia Voiding Straining, hesitancy, incomplete emptying, poor flow, post-micturition (terminal) dribbling Incontinence Stress, urge, overflow, continuous, nocturnal enuresis Also ask about abdo / pelvic pain, sexual hx, obs/gynae hx, previous surgery, systemic sx
36
Haematuria Hx
Duration, no of episodes Onset / progression Timing in stream - initial / continual / terminal Clots Pain (inc abdo pain) Fever / rigors Trauma / exercise LUTS PMHx Prostatic disease, stones, UTIs, TB, bleeding disorders DHx Anticoags, rifampicin SHx exposure to aromatic hydrocarbons (rubber + dye industry)
37
UTI Hx
Dysuria, frequency, urgency, haematuria, odour Fever, acute confusion
38
Chronic renal failure Hx
Oliguria, nocturia, polyuria, anorexia, insomnia, metallic taste in mouth, vomiting, anaemia, fatigue, pruritis, oedema, bruising/bleeding, uraemic fetor
39
General MSK / Rheum Hx
HPC SOCRATES Joint pattern Numbness, tingling, weakness in limb MSK / Rheum sx Systemic sx Previous episodes / tx Trauma Recent infection Loss of function / interfere with life Weight bear Locking / giving way PMHx Diabetes, TB, psoriasis, IBD, coeliac, autoimmune conditions Gout RFs - alcohol, renal disease, diuretics, HTN, obesity DHx Meds, OTC SHx Hand dominance Occupation - affecting work, sports/hobbies Home, ADL Smoking, alcohol, recreational drugs FHx RA, OA, psoriasis, IBD, connective tissue disease, autoimmune disease, gout
40
MSK / Rheum sx
Pain Stiffness - timing (diurnal), duration Swelling Deformity Erythema / hot Exacerbating / alleviating - exercise/heat Reduced ROM Crepitus Giving way / clicking / non-weight bearing Distal weakness / numbness / paraesthesia Fever, fatigue, malaise, weight loss Rashes, ulcers, Raynaud's, Nail changes / pitting Lumps - Bouchard's/Heberden's Nodules (elbow) Hair loss Dry eyes / mouth SOB (RA) Change in bowel habit, abdo pain GU discharge, dysuria
41
Back pain Hx
SOCRATES Pain at rest/movt Sleep disturbance MSK / rheum sx Low mood / stress Fracture Trauma Midline tenderness Deformity Cauda equina sx Bilateral leg pain Urinary / faecal incontinence / retention Numbness, paraesthesia, weakness Decreased anal tone Saddle anaesthesia Infection / cancer sx Age <20/>55 Fever, wt loss, night sweats Recent infection Hx of cancer IVDU Immunosuppression Spondyloarthropathy sx Early morning stiffness Night pain Worse at rest Sciatica sx Radiates down back of leg
42
General PVD Hx
HPC SOCRATES Chest pain, erectile dysfunction PMHx Stroke, IHD, angina, vascular problems, surgery High cholesterol, diabetes, HTN DHx Anticoags, statins, cardiac drugs, anti-HTN, COCP SHx Occupation, smoking, alcohol, diet, exercise, recent travel FHx Coagulopathies Atherosclerosis
43
Acute ischaemia Hx
pain, pallor, pulseless, paralysis, paraesthesia, perishingly cold
44
AAA Hx
Back pain, abdo pain, collapse
45
DVT Hx
Pain, ache Tender Swelling Warm Altered skin colour Unilateral
46
Intermittent claudication Hx
SOCRATES How far they walk Distance staying the same/decreasing How long for pain to ease Bending forward relieve pain? Pain/weakness, tingling, numbness in legs Impotence Leg skin changes RFs for PVD HTN, high cholesterol, DM, smoking, FHX PMHx Angina, MI, stroke
47
General Thyroid / Endo Hx
HPC Onset, duration Change in: - weight - appetite - voice - bowel habit - energy - mood - concentration - heat tolerance / sweaty - skin/nails/hair - HR / rhythm - menstrual cycle Neck lump, tremor, lethargy PMHx Thyroid disease, surgery, tx, HTN, DM, TB DHx thyroxine, lithium, amiodarone, glucocorticoids SHx Smoking, alcohol, diet, ADL FHx Thyroid disease, DM, pituitary tumours...
48
Diabetes Hx
Frequency of urination Thirsty? Weight change Lethargy Eyesight problems Regular infections Tingling / numbness in hands/feet Impotence DHx Steroids SHx Diet + exercise, smoking, alcohol, occupation FHx DM
49
Sexual hx
Intro - some questions sensitive, will include details about sex / sexual partners - stress confidentiality HPC - explore sx - discharge (urethral / vaginal/rectal) - dysuria - swellings/growths/ulcers - pain (anogenital/pelvic/dyspareunia) - PV bleeding, menstrual hx - testicular pain/swelling, penile changes/itching/swelling - fever, malaise, wt loss, rash, swelling/tenderness of joints, conjunctivitis Partners - ?sex with men/women/both - last sexual encounter, type of sex, contraception use etc - was this regular/casual partner - if regular - how long been with - any other partners in last 3mo (then ask same qs again) - feel safe with partner? Any violence / unconsensual encounters? Any procedures to genitals like cutting/piercing? BBV risk assessment - partners from countries with high HIV/hep prevalence - MSM - needle sharing / injecting drugs - sex work - paying/paid - partners known HIV+ - chemsex - tattoos / piercings PMHx - previous STIs, tests - HIV / hep B/C status - vaccinations, inc hep B, HPV - previous obstetric/gynae issues DHx - meds, allergies - contraception, adherance - PrEP use SHx - alcohol, smoking, recreational drug use - sexual problems, eg premature ejaculation
50
Gynae hx
HPC - SOCRATES, explore sx - PV bleed (intermenstrual, post-coital, post-menopausal), - abdo/pelvic pain - PV discharge, - dyspareunia, - vulval itching/skin changes, - infertility - urinary sx - bowel sx - abdo distension - fever, fatigue, wt loss - chance of pregnancy (4 Ps - PV bleed, PV discharge, pain, pregnancy) PMHx - menstrual hx - obstetric hx - sexual hx - date last cervical smear, results - surgical hx - previous gynae issues - previous STIs DHx - contraception, HRT - meds, allergies FHx - breast, ovarian, endometrial cancer, diabetes, bleeding disorders SHx - wt change - occupation, home, smoking, drinking, diet, exercise
51
Menstrual hx
- length of cycle, ?regular - duration of period - volume of bleed - eg heavy - dysmenorrhoea - more painful than usual - LMP - menarche - date of menopause if post
52
Obstetric hx
HPC - N+V, fetal movts, PV bleed, abdo pain, PV discharge, headache/visual disturbance, oedema, pruritis, unilateral leg swelling, chest pain/SOB, fatigue/fever/wt loss Previous obstetric hx - gravidity, parity - gestation at birth, mode of delivery, birth weight, complications, neonatal support, midwife/obstetric care, IVF etc - current children - ages etc - any previous miscarriages - causes - previous TOP, type - previous ectopics - site, management, cx Current pregnancy - LMP, when had +ve pregnancy test - gestational age - folate use - estimated date of delivery - birth plans - scans / screening results - eg 20 wk scan, Down's - any problems / admissions in this pregnancy PMHx - as per DHx - allergies, meds - immunisations FHx - eg SCA, CF SHx - thoughts about pregnancy - occupation, home, family, smoking/drinking - domestic abuse
53
Breast / breast lump Hx
54
Fertility hx
"I understand you've been having some difficulty getting pregnant, can you tell me more about this please?" General - how long been trying - regular, unprotected sex - previous Ix - previous medical tx - previous IVF Sex - frequency of sex - difficulties with sex - relation to fertile days? - pain Consider in partners (each) - age - occupation - BMI - previous children - same/different partner - smoking / alcohol - current meds - PMHx Woman's gynae health - gynae systems review - PCOS sx - hirsutism, obesity, infrequent periods - prolactinoma - galactorrhoea - miscarriages, TOPs, any previous births (primary/secondary failure to conceive) - menstrual hx - obstetric hx - sexual hx - cervical smears, contraception hx - vaccinations - eg MMR PMHx - abdo/pelvic ops, STIs/PID, previous subfertility DHx - folic acid, allergies, meds FHx - eg genetic problems, blood problems (SCA, thalassaemia) - fhx of early menopause SHx - smoking, drinking, vaping, recreational drugs - diet, exercise, occupation
55
Paediatric hx
HPC - SOCRATES, explore sx - fever, activity/behaviour, rashes - cough +/- sputum, runny nose, SOB, cyanosis - vomiting, diarrhoea, abdo pain - wet nappies, dysuria, frequency, haematuria - seizures, fits, headaches, abnormal movts - sore throat, ear pain Birth - any problems in pregnancy - place of birth, gestation, weight, mode of delivery, complications, neonatal requirements Growth - weights - the Red Book - puberty Feeding - eating / drinking, how much / how many bottles - frequency of wet nappies / stools, consistency Development - any concerns PMHx - previous medical / surgical problems, previous hospital visits DHx - meds, allergies, immunisations FHx - as normal SHx - who's at home, siblings/parents - any smokers - social services input - housing, hobbies, school, pets ICE
56
Back pain hx
57
Derm hx
HPC - SOCRATES - Where, when it appeared, how it’s changed - Sx – itch, pain, rash, skin lesion, bleed, discharge, blisters, fever, malaise, wt loss, arthralgia - Exacerbating / relieving factors - Tx tried - Recent contact, stress, illness, travel - Hx of sunburn, use of tanning machines - rheum system review PMHx - Atopy – asthma, allergic rhinitis, eczema - Skin cancer, suspicious skin lesions FHx - Skin disease SHx - Occupation (inc skin contacts at work) - Improvement of lesions when away from work - alcohol, drugs, smoking - home environment - changes in diet DHx - Inc OTC
58
ENT Hx
HPC - SOCRATES - general - fever, chills, wt change - ear - tinnitus, vertigo, hearing loss, pain, discharge - nose - congestion, rhinorrhoea, epistaxis, decreased smell - throat - pain, dysphagia, odynophagia - larynx - hoarse, voice change, noisy/difficulty breathing, pain speaking - neck - swellings, pain, lumps - face - sinus pain, pressure, swelling, numbness PMHx - previous surgery, eg head/neck DHx - meds, allergies SHx - smoker, alcohol FHx - anything in the family
59
Ophthal hx
HPC - SOCRATES, explore sx - sudden vision loss - change to vision - nature, onset, duration - red eye - eye discharge / watering - gritty / dry eyes - itchy eyes - photophobia - swelling / tenderness of eyes - eye pain / pain on eye movt - SOCRATES - double vision - flashing lights - headache/fever - bleeding / trauma to eye - nature of injury, mechanism, FBs - abnormal pupil reactions? - temporal tenderness / jaw claudication PMHx - previous eye surgery, laser, trauma, contact lens/prescriptions - chronic / autoimmune conditions DHx - eye drops? SHx - smoking
60
Psych hx
HPC - explore sx - nature, onset, tx, severity (functional impact), exacerbating/alleviating, duration/progression - impact on life - psychosis - hallucinations, delusions, thought disorder - irrational thoughts, seeing/smelling things, feel targeted - depression - low mood, anhedonia, sleep/energy, hopelessness... - mania - periods of elation, out of character - cognition - memory loss/forgetful - anxiety, panic attacks, phobia - unhappy about bodyweight / can't control eating - insight Risk assessment - intention to harm self, anyone else - suicidal thoughts - action on these thoughts - risk of harm from anyone PMHx - psych issues - dx, tx - past contact with mental health services - previous self-harm/suicide attempts - medical hx DHx - meds, allergies - compliance FHx - psych issues, suicide SHx - alcohol, smoking, drugs - current home, relationships, dependents/children, work, education - forensic hx - police, jail, criminal record - upbringing hx - childhood, school, inc child abuse
61
Self-harm / suicide hx
HPC - before - eg life events, depression - planning - how long for / impulsive - suicide note / tell anyone? - precautions to avoid being found - any alcohol/drugs - truly intend to end life? - when / where / how - eg specific OD details, self-harm injuries, where they got meds from etc - how were they found / how did they get here - feelings after the event - angry/regret - current mood - anything stopping them commit suicide? - If they went home what would they do? - any future plans for suicide - happy to accept tx? - depression screen - low mood, anhedonia, sleep/energy... - psychosis - hallucinations, delusions... - anorexia - problems with eating habits / body image - safe at home? any risk from others? PMHx - conditions, inc psych - past suicide attempts/self-harm - methods, help sought DHx - meds, inc allergies FHx - self-harm/suicide, psych conditions SHx - drug / alcohol, social stresses, relationship/family, jobs, living situation, hobbies
62
Psychosis hx
63
Depression hx
64
Mania hx
65
Eating disorders hx
66
Psych risk assessment (self-harm/suicide)
- any thoughts of self-harm - any thoughts of harming others - any suicidal thoughts - any harm from others? - any attempts to self-harm / commit suicide - what stops you acting on these thoughts - made plans for suicide? What are they? - how do you feel afterwards? - take steps to ensure not found? - support system at home - any triggers for these feelings? - any dependents?

Phase 4 OSCE (4 decks)

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