history taking

History Taking: Patient with low mood (depression)

History taking: psychiatry case

Mental health station is commonly tested in the OSCE as it makes up a large proportion of consultations in both primary care and also influences decisions in secondary care. The examiners want to ensure that the candidate has a sound understanding of the questions to ask, the red flags to rule out and the communication skills for a smooth consultation.

Important factors:

  • listening is far more important than talking.

  • show empathy with verbal and non verbal communication, whether that is with head nodding or saying “OK, I see”. Listening skills are important in ALL stations, but this one in particular!

  • if the patient cries, be silent and to break the silence say something empathetic “I can see that you are very upset”

  • ask about suicide, do not be afraid to ask this. Ask sensitively.

  • use the patients own words when reflecting what they have said. This shows you are listening and not making your own interpretation

    • “tell me more about ‘feeling alone and desperate’?”

  • Social history is just as important as all other components. Candidates often feel this doesn’t require as much attention, but this is not true. Knowing who the patient lives with, their support network, if they go to university/work will firstly allow safety netting (if they were suicidal) and also builds rapport.

Below is a summary of the questions to ask and why (as knowing the ‘why’ makes it a whole lot easier to remember!) I have focused the history on low mood to make it easier to discuss.

PRESENTING COMPLIANT

“How can I help you today?’

Let the patient talk and express themselves. The first 1 minute (‘golden minute”) will tell you mostly what you need to know. Listen to them, make a mental note/physical note of the important statements they used

HISTORY OF PRESENTING COMPLIANT

Core symptoms

This is where you want to know if they have the specific “core symptoms” of depression.

"Have you in the last month felt persistently low in mood?”

“Have you in the last 1 month lost interest in things that used to interest you?”

“Have you in the last 1 month felt low in energy?”

Biological symptoms

With depression, patients also have other ‘biological symptoms” along with the core symptoms.

“Are you sleeping?” “Have you had issues with your sleep?”

This may be OVER sleeping or UNDER sleeping.

“How is your appetite?” “Are you eating less/more”

They may over eat/under eat. Remember depression can go hand in hand with an eating disorder. Of course this is something you will not be able to cover in a 10 minute station.

“Have you noticed a change in your libido?”

Remember low mood doesn’t just affect the patient, but also loved ones. It has a significant impact on relationships.

Cognitive symptoms

  • change in concentration

  • how they feel about themselves and the world around them

Associated psychiatric conditions

With depression, patients can suffer from associated psychiatric conditions ie eating disorder or psychosis. Here you need to ask questions to rule this out:

“Have you ever worried about your weight?” - eating disorder

“Have you ever felt euphoric?” - Mania (bipolar)

“Have you ever heard voices when no one is ever around?” psychosis (auditory hallucinations)

“ Have you ever seen something that you couldn't explain?” psychosis (visual hallucinations)

“Do you ever feel like people are talking about you behind your back?” psychosis

Candidates find it odd asking the above questions, so you can always start with

“these questions may sound odd, but it is important we discuss them” This also gives a warning shot to the patient.

The above questions may need examples if the patient is not understanding you ie “Do you feel like like people are speaking about you negatively, ie you feel like people are out to get you?”

RISK ASSESSMENT

Vital questions that have to be asked in a patient presenting with suicidal thoughts/deliberate self harm:

  1. ask about suicide, do not be afraid to ask this. Ask sensitively. There are lots of different ways ie

    • “have you ever thought life was not worth living"?”

    • “do you ever wish you weren’t here"?”

    • “do you feel the world would be better without you”

  2. Ask about self harm

    • “Do you have thoughts about harming yourself?

    • “Have you ever harmed yourself”

If they say they DO have thoughts of harming themselves or DO have thoughts of wanting to end their lives, the next best step is to ask about protective factors: essentially what would STOP them from hurting/killing themselves. Working as a GP, this question is essential for me to evaluate “risk” and my next step. Also, having an idea of the patients social set up will help me, ie do they live alone, do they have lots of friends around them.

“I really appreciate you being open with me about these thoughts you are having, it must have been so difficult to say this” “What stops you from actually ending your life"?”

Most patients will say ‘oh i don’t actually want to, its just fleeting thoughts” some say “my family, my children, my dog, religion”.

PAST PSYCHIATRIC HISTORY

You want to find out if they have 1) seen their GP for their mental health in the past 2) Been on medications for mental health issues 3) been admitted into hospital for mental health issues

This will put the above information into context. Is this is a patient who has been sectioned for mental health problems? - this is more worrying than a patient who has never been on any medications.

PAST MEDICAL HISTORY

The same questions as other history taking stations

DRUG HISTORY

Same as other history taking stations

additional factors:

If they have taken antidepressants/anti psychotics in the past /currently, you need to know 1) what medications 2) the dose 3) for how long.

FAMILY HISTORY

Same questions as other stations but with additional questions around mental health issues in the family. Many mental health problems run in the family. Also you want to know if the patient grew up around a parent with depression, or a parent who committed suicide.

SOCIAL HISTORY

  • alcohol, drugs, smoking

  • forensic- have they ever been in trouble with the police

  • student/working - how has their mood impacted this

  • relationship - are they single? do they find it difficult to form relationships

  • who do they live with?

  • Do they speak to their friends and family? (support network)

INSIGHT

You may want to ask this if the patient has come with a relative who is worried. Does the patient actually see that they may have depression? Having insight makes the management different to someone who is not aware they they have a mental health problem.

ICE

Same questions as other history taking station

I hope you found this information useful. It is not a comprehensive guide and there to just get you thinking and reflecting on your own style of history taking.

Please feel free to send me an email if you have any question, queries or corrections!

Also if you would like to have one-to-one revision, again either send me an email and we can arrange one hour (free!) of discussing your needs and how i can be of help with your revision. Or you can sign up via the website.

Please follow my twitter/instagram/facebook for further quick bites of information.

Happy revision :)

















History Taking: Ideas, Concerns and Expectations

History take: ideas, concerns and expectations

Welcome to my blog page, thank you for taking the time to read this, I hope you are all well during these odd times.

“Ideas, concerns and expectations” commonly referred to as "‘ICE’ can be questions that make you feel uncomfortable. It can feel like it stops the flow, feels out of place and repetitive.

This blog will outline WHY it is important and HOW to integrate it into your history, so it flows better. As without the KNOW- it’s difficult to truly remember to the ask the questions with conviction.

The example questions are just examples, you should find what is comfortable for you!

IDEAS

“What do you think is going on?”

“What are your ideas on what might be causing these symptoms?”

Why are we asking this?

Essentially you want to know what is on the patients mind. You want them to say what they think might be going on, which could be completely irrelevant. Getting their prospective on what they think the cause of their symptoms are, will introduce a starting point for when you are telling them what YOU think their diagnosis is.

Putting it into context:

“Mrs Smith, you suggested you thought you may have asthma, well taking your shortness of breath and noisy breathing into account, this does seem very likely”

CONCERNS:

“Was there anything you were particularly worried about?”

“You did say you were worried about cancer, do you have any other worries?”

Why are we asking this?

We want to know what worries the patient the most, which might NOT always be their “ideas”! They might think they have asthma (ideas), but worried it could be lung cancer (concerns). Patients/actors are complex, they have many worries and anxieties, which they don’t always discuss, so it is our job as doctors to bring this out.

Putting it into context:

“Sheila, you said you were worried you might have cancer like your brother, tell me more about this”

EXPECTATIONS:

“What were you hoping for from todays consultation?”

“How can I best help you today?”

Why are we asking this?

You want to get an idea of what the patient wants from today, do they want a blood test? Do they want you to reassure them, the list is endless. Knowing the “expectations” can be nicely linked to the diagnosis/management of the patient. Again, we feel this is an odd question- they are worried about cancer and they OBVIOUSLY want me to rule this out? This is not always the case.

Putting it into context:

“George, you said that you would like a chest X-ray for this persistent cough, well I agree that would be a good next step”

I hope you found the information useful and easy to follow. I do believe that practice makes perfect, so whether that is practicing with friends or signing up for one-to-one revision with myself- keep focused :)

Remember this exam is like a driving test- everything has to be obvious and exaggerated for the marks. Make the examiner’s life easy and SHOW them the marks!

Happy revision :)





History Taking: Breaking Bad News

History taking: breaking bad news

This station is a favourite amongst ALL OSCE exams throughout training. Whether it is breaking bad news about a new cancer diagnosis or telling a patient they cannot safely drive anymore.

The mnemonic that is commonly used is: SPIKES which stands for : Setting, Perception, Invitation, Knowledge, Emotions and Summary

SETTING:

  • Set the scene, get the chairs in the correct format to reduce fumbling in the exam

  • ensure private setting (you may need to verbalise this to the examiner!)

  • Ask the patient to come in, ask if they have anyone with them that would like to join

PERCEPTION:

  • Introduce yourself.

  • Ask the patient why they have been asked to come in, i.e. the reasons for the the bloods/chest x-ray/investigation.

    “So why have you been asked to come to see me today?”

    “I have been asked to discuss your chest x-ray, could you tell me what led up to your GP arranging this?”

    • This will allow to a) Building of a rapport b) Get their perception on their symptoms so you can then correlate this to the interpretation of the results, i.e a patient coughing up blood with a suspicious lesion on a chest x-ray. You will use their ‘perception of their symptoms’ later when breaking the bad news.

  • DO NOT jump in with giving the information. These 1-2 minutes of getting the patient to speak could make or break the success of this station

INVITATION:

  • Let the patient know that you are going to discuss the results/letter etc but BEFORE doing this, ask them WHAT and HOW much they want to know.

  • Some patients do not want all the information, some want it all. Again rapport is vital.

    ”Some people do not like to be given all the information at once, whereas others want to know everything. What would you prefer?”

KNOWLEDGE:

  • Give a “warning shot”, pause, and then continue.

    ”We have your blood tests results which might explain why you were experiencing night sweats and weight loss, which you were worried about” (link the “perception” here, it will flow nicely)

    ”George, I have the results of your chest xray (pause)..i am so sorry…(pause) it is not good news” PAUSE.

  • Provide information in small junks. Give space for the patient to react and acknowledge the information. It is so easy to just plough on with information, BUT the marks are not in your knowledge of lung cancer but in the rapport you built with the patient by how you made THEM feel.

EMOTIONS:

  • This means to stop and reflect the patients emotions back to them

    ”I am so sorry, I can see you are understandably upset”

    ”Would you like a tissue?” (Make sure there are tissues otherwise don’t ask!)

  • Do not fill the (awkward) gaps with talking, silence is precious. If they are crying, it will not help talking over them.

STRATEGY/SUMMARY

  • Leave 1 minute to put a plan together of the next step

  • Give a Patient Information Leaflet

  • Check their understanding of what has been said (sensitively)

  • Ask if they have any questions/anything they did not understand

  • Suggest a follow up date after they have absorbed the information/spoken to love ones

I hope you found the information relevant and useful.

We worry about these stations incase we come across as too abrupt or that we will freeze when the actor/patient starts crying… My one advice for success is - just listen and show empathy. It will feel odd sitting opposite someone crying/getting angry, but if you take a step back and listen, the examiner will give you marks for being human.

Stay focused and happy revision :)

History taking: RED FLAGS

History Taking: Red flags

When taking a history, make sure to remember the “red flags”. It is vital to show the examiner (who is looking at you as a possible future junior doctor) that you are a COMPETENT and SAFE doctor.

Below are a list of red flags based on systems. The list is not exhaustive and is just a guide for some common important questions.

In the (brackets) I have provided possible reasons for the questions.

Cardiology:

1) Progressing chest pain - (ACS)

“Is the chest pain getting worse?” “Is the pain now occurring at rest?”

2) Dizzy spells associated with : shortness of breath (? PE) loss of consciousness (lack of cerebral blood flow) palpitations (cardiac origin)

“Are your dizzy spells associated with loss of consciousness etc?”

Respiratory:

1) chest pain + shortness of breath

“Do you have any chest pain?” (ACS)

2) Leg swelling (1 leg DVT, 2 legs CHF)

“Have you noticed any sudden swelling of your leg/s?”

3) Haemoptysis (PE/Lung cancer)

“Have you noticed any blood in your sputum?” “What colour is your sputum?”

Gastroenterology

1) Weight loss (GI cancer)

“Have you had any unintentional weight loss?” “if so, how much and over what period of time?”

2) Blood in stool (IBD, cancer)

“Have you noticed any blood in your stool?” “What colour are your stools?”

3) Pain on swallowing/food getting stuck (upper GI cancers)

“Have you noticed food getting stuck when you swallow?” “Do you have any discomfort when swallowing food?”

Renal

1) Blood in urine (urological cancer)

“Have you noticed any blood in your urine?” “What colour is your urine?”

Neurological

1) Any new/worsening neurology (Stroke) **This may come in ‘acute station’

“Have you noticed any weakness of your arms/legs/face?”

2) Worsening headaches (SOL)

“Have your headaches got worse over time?” “Is your headache keeping you up at night?”

Musculoskeletal

1) Thoracic back pain (metastases)

“Can you tell me where the pain is exactly?” “Is your back pain disturbing your sleep?”

2) Not being able to weight bear/move joint (fracture/septic joint)

“Are you able to move the ankle?” “Can you put any weight on the foot?”

Psychiatric

1) Suicidal thoughts

“Do you have any thoughts of ending your life" “Do you ever feel that life is not worth living?”

2) Hallucinations

“Do you ever hear voices that others can’t?” “What do these voices say/tell you/do they tell you to hurt yourself or others?”

Endocrine

1) Constitutional symptoms + hyperhidrosis (phaeochromacytoma)

“Where have you noticed the sweating?”

2) Double Vision (Pituitary Adenoma)

“Do you have any double vision?” “When you look at one object, do you see two?”

Dermatological

1) Change in lesion

“Have you noticed any change in colour/size/shape of lesion?” “Does the lesion itch or bleed?”

2) Rash after starting drug (drug allergy)

“Did you notice the rash after starting the antibiotics?” “Did you experience any lip swelling/difficulty in breathing?”

I hope you found this list useful. As I was researching, I realised there are A LOT of questions, but this is not about memorising. It is about having an understanding of WHY you are asking, which will make the remembering easier.

Happy revising :)

History Taking: SOCRATES

History Taking: SOCRATES

Hello fellow medics :)

SOCRATES is a mnemonic for remembering the questions to ask after a patient presents with a ‘complaint’. Although traditionally used for “pain”, it can be adapted to suit any history (give or take!).

Remember SOCRATES/or other mnemonics are there as a prompt, and therefore it is important to have flow and listening skills.

Continue reading below to see SOCRATES broken down with some specific questions which may help.


Site: “Can you tell me in your own words where the pain is?”

“Can you point to where the pain is?”

Non pain history: “Tell me more about how you are feeling”

“Where do you feel this tightness?”

Onset: “When did the pain first start?”

“How long have you had this pain?”

“What were you doing when the (pain/symptom) first came on?”

Non pain history: “When did this shortness of breath come on?”

“When did you start to feel low?”

Character: “Describe the pain to me” (you may need to prompt the patient if they cannot find the words) “is it a stabbing pain, a dull ache, does it come and go?”

Non pain history: “Describe the colour/consistency of the stool”

“How would you describe the lump- hard, soft?”

Radiation: “Does the pain travel anywhere?”

“Is the pain just in the one place?”

Non pain history: NA

Associated symptoms: “Is there anything else you have noticed with this pain?” (this will be based on the system involved i.e. with chest pain: “Do you have shortness of breath?” etc)

Learn the associated symptoms with each presenting complaint - luckily there are lots of overlap.

Timing: “When does the pain come on?”

“Does it come and go depending on what you eat?”

“Is the pain constant?”

Non pain history: “When do you feel sick? Any specific time of the day?”

Exacerbating/Relieving factors: “What makes the pain better?” (ie movement, medications)

“What makes the pain worse?”

Non pain history: “What makes the groin lump bigger?”

“How do you manage the stiffness in your joints?”

Severity: “can you tell me how bad the pain is on a scale of 1-10?”

“What impact does this pain have on your daily activities?”

“What is this pain stopping you from doing?” (referring to the impact on ADLS- Activities of Daily Living)

Non pain history: “How far can you walk before being breathless?”

“How is your mood impacting your sleep/ability to function?”


Flow is essential in taking a history, and so a mnemonic is ideal for when your flow disappears due to anxiety of the OSCE station…and you need something to put you back on track.

Any further questions, please don’t hesitate to email/DM me- I am here to help and guide :)

Happy revising :)