History taking question

[gregoryhouse]

Hi guys, I'm a first year student and every week we have practice OSCEs depending on what organ system/block we are working on that week.

Anyway the scenarios are generally easy to figure out, but I often get deducted points for not asking specific symptoms or questions even though I generally figure out the correct diagnosis.

As I understand it, on the OSCE exams it is generally better to spend most of the time communicating even if the diagnosis is obvious. So I want to ask for tips so I can be better prepared to handle these type of practice OSCEs in the future.

Let me briefly describe the way I generally format my history taking.

I get the chief complaint, then HPI, ROS, PMH, PSH, Meds, Fam Hx, Soc hx, differential diagnosis in that order always so I generally can remember a set list of questions in that order.

My main problem is that I feel like I rely too much on open ended questions, such as, "do you have any other symptoms", "what medications are you taking?", etc. It seems like a lot of the time, there are certain questions that they really want you to specifically ask on these exams, (i.e., have you had any nausea or vomiting? For a GI patient).

I can generally remember to ask certain questions but sometimes I tend to not ask specific questions if the standardized patients say they don't really have any other symptoms when I ask it in an open ended question.

Also when I'm asking about medications, I usually don't ask for specific meds unless they say something like they can't remember exactly the name of the drug.

So can you guys give me any tips for history taking to make it a little bit easier and go smoother?

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[sobored]

Try to focus your HPI using the relevant ROS section. Example: pt presents with abdominal pain --> aside from the normal "where does it hurt, describe the pain" type questions, ask the relevant GI, GU, reproductive questions right then and there. In other words, don't wait until you think it's the right time to ask those questions in some kind of order, use the ROS to help guide your questioning based on what organ system/region the patient is complaining about. Regarding drugs, I always ask for specifics. Sometimes they know, sometimes they don't, but always ask. I don't know if I've helped you in any way, but that's my 2.

 

[madchemist89]

It sounds to me like you are missing the pertinent positive and negative questions. In order to ask these questions, you have to begin forming your differential in your head as you interview the patient. However, the key to knowing which questions to ask is knowing the various pathologies. Taking acute diarrhea as an example, you could ask the following questions. Have you traveled recently? Have you gone camping? Is it bloody? Does it smell really bad? Does it float? These questions will help you rule in or out different causes of the diarrhea.

My preferred order for history taking is: HPI, Meds/Allergies, PMH, FMH, then social hisory. As I go through the interview, I actively think about the problem as the patient tells me what is going on, and this technique allows me to know when to be more specific and what to focus on.

 

[ShinyDome19]

I had this problem with standardized pts .. its not that you are necessarily doing anything wrong, its just that standardized pts are completely unrealistic. For instance, I usually just ask pts if they have any problems going to #1 or #2, but since I didn't specifically ask if they were constipated, I lost points.
The best thing to do as a first year is to either learn to play their stupid games or just get over the fact that you might lose a few points for not playing the way they want you to.

One person said to focus your exam..ignore that...your a first year...there are 3rd and 4th years that are still learning that.

 

[SouthernSurgeon]

Here's how I would analogize it. When I was in high school math classes, I was constantly getting in arguments with my teacher, because I would ALWAYS get the right answer, and she would ALWAYS take off points for not showing my work. I would frustratingly point out that it isn't like I'm guessing here, I just did the work in my head. Didn't matter, she said, she wanted me to demonstrate it.

OSCEs aren't about "getting it right". They are about showing your work. So you have to approach each one the same way, every time. It doesn't matter that you figure out in 2 seconds that they have acute pancreatitis. It matters that you take a comprehensive focused GI history and ask all of the pertinent questions. Learn to play the game. For each organ system you should have a standard block of focused questions to ask. These are easy to find in a PDx textbook, or in first aid for step II cs.

 

[Psai]

It's hard to understand before you get through the organ systems but real patients aren't as easy as standardized patients. You don't get leading statements and a "right answer". It's a mystery that you're trying to solve. As soon as you get a chief complaint, you immediately try to think of everything it could possibly be, focusing on what's most likely and what can kill you. Chief Complaint: Chest pain. You don't go immediately to "you're having a heart attack". You can't do a coronary artery bypass graft on every person presenting with chest pain. So you form a differential: myocardial infarction, unstable angina, aortic dissection, pulmonary embolism, pericarditis, costochondritis, etc. You go through the oldcarts or opqrst and you ask things like where is it, is it constant or does it come and go, does it occur at rest or in exertion (maybe unstable angina vs mi), does it radiate to your left arm or jaw, does it feel like something is ripping into your back, how severe it is, whatever. And just because it's in the chest doesn't mean it has to be something in the mediastinum. It could be gastroesophageal reflux disease, hiatal hernia or even something like a panic attack. So you go through and ask pertinent positives and negatives for the things you're thinking about and then you go through the review of systems to see if there's anything you missed because patients don't read the textbook before they come to see you. This process helps you narrow down your differential until you get to the most likely diagnoses.

Practice all the questions now and you'll know what to say later. Listen to your patient, they are telling you the diagnosis. But they won't tell you if you aren't asking.

 

[sobored]

I had this problem with standardized pts .. its not that you are necessarily doing anything wrong, its just that standardized pts are completely unrealistic. For instance, I usually just ask pts if they have any problems going to #1 or #2, but since I didn't specifically ask if they were constipated, I lost points.
The best thing to do as a first year is to either learn to play their stupid games or just get over the fact that you might lose a few points for not playing the way they want you to.

One person said to focus your exam..ignore that...your a first year...there are 3rd and 4th years that are still learning that.

I said to focus the HPI, not the entire exam. Asking the pertinent questions from ROS relating to the chief complaint will help the OP continue their line of questioning and pick up on things they might have otherwise forgotten to ask. You can do things however you want, but it's ridiculous to be dismissive of advice that might help someone else.

 

[ShinyDome19]

I said to focus the HPI, not the entire exam. Asking the pertinent questions from ROS relating to the chief complaint will help the OP continue their line of questioning and pick up on things they might have otherwise forgotten to ask. You can do things however you want, but it's ridiculous to be dismissive of advice that might help someone else.

Wow man, I wish I went to your school. We didn't really learn what ROS questions were pertinent until 3rd and 4th year.

You must be awesome bro.

 

[gregoryhouse]

Thanks for the advice everybody. I'll try to keep all these things in mind for next time.

 

[Bacchus]

I had this problem with standardized pts .. its not that you are necessarily doing anything wrong, its just that standardized pts are completely unrealistic. For instance, I usually just ask pts if they have any problems going to #1 or #2, but since I didn't specifically ask if they were constipated, I lost points.
The best thing to do as a first year is to either learn to play their stupid games or just get over the fact that you might lose a few points for not playing the way they want you to.

One person said to focus your exam..ignore that...your a first year...there are 3rd and 4th years that are still learning that.

There have been numerous times I've asked patients if they've had trouble with bowel or bladder habits and they've said no, to which I target the questions more: "Are you constipated, having diarrhea, waking up to use the toilet at night, having trouble holding or starting your urine, etc." The patients usually answer something positively despite denying problems urinating or passing a BM previously. You shouldn't be using blanket statements at this time such as "any trouble with the bathroom? any problems with your blood? (instead asking about easy bruising, bleeding, family disorder)" The diagnosis is usually in the history and taking a little longer with that before moving on to physical exam will help you innumerably. Physical exam, labs, etc should guide your thoughts, but you should have a good idea of several diagnoses in your head before you get there.

 

[ulikedaggers]

I said to focus the HPI, not the entire exam. Asking the pertinent questions from ROS relating to the chief complaint will help the OP continue their line of questioning and pick up on things they might have otherwise forgotten to ask. You can do things however you want, but it's ridiculous to be dismissive of advice that might help someone else.

Pretty sure the vast majority of us first years don't know what's pertinent from ROS.

Or maybe I'm just really really dumb.

 

[mvenus929]

As a first year, asking the right questions is hard, because you don't know all the pathologies that could present. Even as a fourth year, I forget to ask questions pertinent to rule out or in various diagnoses. Developing a good ROS will help with that, but you're not going to get good at it as a first or second year.

 

[SouthernSurgeon]

As a first year, asking the right questions is hard, because you don't know all the pathologies that could present. Even as a fourth year, I forget to ask questions pertinent to rule out or in various diagnoses. Developing a good ROS will help with that, but you're not going to get good at it as a first or second year.

You can at least start the process of getting good at it. I wouldn't expect a first year to be nailing every secondary or tertiary question. But I would expect them to do a little more than ask "is there anything else wrong?"

 

[TooMuchResearch]

You can at least start the process of getting good at it. I wouldn't expect a first year to be nailing every secondary or tertiary question. But I would expect them to do a little more than ask "is there anything else wrong?"

I recall being totally stumped by non-pain related presentations in MS1/2. If I couldn't OPQRST it, I didn't know what to do with it, so I would ask a massive, unfocused ROS to try to scrape up anything useful.

 

[Psai]

I recall being totally stumped by non-pain related presentations in MS1/2. If I couldn't OPQRST it, I didn't know what to do with it, so I would ask a massive, unfocused ROS to try to scrape up anything useful.

Yeah we had a patient present with "I think I have an STD" as a chief complaint on an exam and I was like wtf... totally blanked. I never felt worse coming out of an exam. When everyone else came out of their rooms, they had OLDCARTS written on their paper and it was completely blank which made me feel better.

 

[ulikedaggers]

I recall being totally stumped by non-pain related presentations in MS1/2. If I couldn't OPQRST it, I didn't know what to do with it, so I would ask a massive, unfocused ROS to try to scrape up anything useful.

So much this. Depressed patient? Yeah, sorry idk what to do.

 

[ShinyDome19]

There have been numerous times I've asked patients if they've had trouble with bowel or bladder habits and they've said no, to which I target the questions more: "Are you constipated, having diarrhea, waking up to use the toilet at night, having trouble holding or starting your urine, etc." The patients usually answer something positively despite denying problems urinating or passing a BM previously. You shouldn't be using blanket statements at this time such as "any trouble with the bathroom? any problems with your blood? (instead asking about easy bruising, bleeding, family disorder)" The diagnosis is usually in the history and taking a little longer with that before moving on to physical exam will help you innumerably. Physical exam, labs, etc should guide your thoughts, but you should have a good idea of several diagnoses in your head before you get there.

For the most part I agree with you Bacchus. You have to use blanket statements with some level of caution. However, you cant really interview a real patient without using them in some fashion. For instance, I always ask patients "do you have any other medical problems, such as High Blood Pressure or Diabetes?", to which I have had some of the most obese people, laying in a stretcher in a cold ass room, sweating and gasping for air reply - "No I have always been pretty healthy man". Then the next question "what medicines do you take?" - "I take HCTZ, Lasix and Metoprolol"...
So, unless your going to ask your patients if they have every disease listed in Harrison's, you use blanket statements.

With ROS, I typically think it is is appropriate to cover every major system when interviewing a patient. The only way to do so in a timely manner is with blanket statements. If a pt's CC is Headaches, typically ill go deep into neuro, HEENT and constitutional questions, then blanket the rest of the systems: "problems going bathroom #1 or #2, new aches or pains anywhere...etc. If a patient is dropping friends off at the pool that are covered in blood, and it's not significant enough for them to say yeah I am poop'n blood...while it would be good to know, in reality its not going to prevent me from treating their CC. Furthermore, blanket statements protect you from those infamous patients that respond yes to every frick'n ROS question...which I think is more harmful to coming up with a diagnosis than not having some information.

But, back to the context of the OP's questions - the use of blanket statements with standardized patients, on weather they are good or not, really depends on the actor. At least at our school, some of them were nurses (you could tell b/c they would hang their white coats up off to the side in the room) and when you asked them if they had any problems going to the bathroom, they would know when their script said "you have hematuria"...that it was proper to respond with "YES i pee blood sometimes". But your average Joe off the street that follows their script to the letter, doesn't really have a clue how to respond to the blanket questioning...its really a crap shoot. I for one preferred using the blanket statements to cover all the systems rather than risk running out of time on a more significant part of the exam.

 

[TooMuchResearch]

Yeah we had a patient present with "I think I have an STD" as a chief complaint on an exam and I was like wtf... totally blanked. I never felt worse coming out of an exam. When everyone else came out of their rooms, they had OLDCARTS written on their paper and it was completely blank which made me feel better.

Go full force open ended: Why do you think you have an STD? And go from whatever they tell you.

 

[sobored]

Wow man, I wish I went to your school. We didn't really learn what ROS questions were pertinent until 3rd and 4th year.

You must be awesome bro.

Get real, douchebag. You tell the OP to totally ignore what I said the first time, insult me in your next post, then go on to verbally blow the resident who you agree with "for the most part" - who's advice, by the way, is almost exactly the same advice I gave to the OP. Every first year should have a list of ROS questions that they should be getting familiar with...if the patient has abdominal pain, just ask all the questions for GI, GU, repro from your ROS sheet. Is that so hard? They should absolutely be practicing that as first years because it's tough to get good at, so why not start early?

 

[Bacchus]

For the most part I agree with you Bacchus. You have to use blanket statements with some level of caution. However, you cant really interview a real patient without using them in some fashion. For instance, I always ask patients "do you have any other medical problems, such as High Blood Pressure or Diabetes?", to which I have had some of the most obese people, laying in a stretcher in a cold ass room, sweating and gasping for air reply - "No I have always been pretty healthy man". Then the next question "what medicines do you take?" - "I take HCTZ, Lasix and Metoprolol"...
So, unless your going to ask your patients if they have every disease listed in Harrison's, you use blanket statements.

With ROS, I typically think it is is appropriate to cover every major system when interviewing a patient. The only way to do so in a timely manner is with blanket statements. If a pt's CC is Headaches, typically ill go deep into neuro, HEENT and constitutional questions, then blanket the rest of the systems: "problems going bathroom #1 or #2, new aches or pains anywhere...etc. If a patient is dropping friends off at the pool that are covered in blood, and it's not significant enough for them to say yeah I am poop'n blood...while it would be good to know, in reality its not going to prevent me from treating their CC. Furthermore, blanket statements protect you from those infamous patients that respond yes to every frick'n ROS question...which I think is more harmful to coming up with a diagnosis than not having some information.

But, back to the context of the OP's questions - the use of blanket statements with standardized patients, on weather they are good or not, really depends on the actor. At least at our school, some of them were nurses (you could tell b/c they would hang their white coats up off to the side in the room) and when you asked them if they had any problems going to the bathroom, they would know when their script said "you have hematuria"...that it was proper to respond with "YES i pee blood sometimes". But your average Joe off the street that follows their script to the letter, doesn't really have a clue how to respond to the blanket questioning...its really a crap shoot. I for one preferred using the blanket statements to cover all the systems rather than risk running out of time on a more significant part of the exam.

I'm pretty sure I was talking in the context of the HPI and didn't list any specific diagnosis.

 

[Bacchus]

For the most part I agree with you Bacchus. You have to use blanket statements with some level of caution. However, you cant really interview a real patient without using them in some fashion. For instance, I always ask patients "do you have any other medical problems, such as High Blood Pressure or Diabetes?", to which I have had some of the most obese people, laying in a stretcher in a cold ass room, sweating and gasping for air reply - "No I have always been pretty healthy man". Then the next question "what medicines do you take?" - "I take HCTZ, Lasix and Metoprolol"...
So, unless your going to ask your patients if they have every disease listed in Harrison's, you use blanket statements.

With ROS, I typically think it is is appropriate to cover every major system when interviewing a patient. The only way to do so in a timely manner is with blanket statements. If a pt's CC is Headaches, typically ill go deep into neuro, HEENT and constitutional questions, then blanket the rest of the systems: "problems going bathroom #1 or #2, new aches or pains anywhere...etc. If a patient is dropping friends off at the pool that are covered in blood, and it's not significant enough for them to say yeah I am poop'n blood...while it would be good to know, in reality its not going to prevent me from treating their CC. Furthermore, blanket statements protect you from those infamous patients that respond yes to every frick'n ROS question...which I think is more harmful to coming up with a diagnosis than not having some information.
At your level of education you don't have enough experience to disregard positive review of system findings. Myself or another resident you're reporting to might say, "Yeah, that's not important," but that has come with experience. We also still have a lot to learn. Your job is to report your findings to us and develop over time the ability to assess if chest pain, abdominal pain, or shortness of breath are pertinent. As a student, you're not at the level to just shrug off or assume a patient isn't having a problem with a specific system because they didn't offer it. Thus you ask about BRBPR or blood on the toilet tissue. You ask them if they wake up at night to urinate, or go often, or can't hold it.

But, back to the context of the OP's questions - the use of blanket statements with standardized patients, on weather they are good or not, really depends on the actor. At least at our school, some of them were nurses (you could tell b/c they would hang their white coats up off to the side in the room) and when you asked them if they had any problems going to the bathroom, they would know when their script said "you have hematuria"...that it was proper to respond with "YES i pee blood sometimes". But your average Joe off the street that follows their script to the letter, doesn't really have a clue how to respond to the blanket questioning...its really a crap shoot. I for one preferred using the blanket statements to cover all the systems rather than risk running out of time on a more significant part of the exam.
When you take your CS or PE portion of your Step II, I advise you to ask specific review of system questions and do not group them together.

 

[ShinyDome19]

Get real, douchebag. You tell the OP to [1]totally ignore what I said the first time, insult me in your next post, then go on to [2]verbally blow the resident who you agree with "for the most part" - who's advice, by the way, is almost exactly the same advice I gave to the OP. Every first year should have a list of ROS questions that they should be getting familiar with...if the patient has abdominal pain, just ask all the questions for GI, GU, repro from your ROS sheet. [3] Is that so hard? They should absolutely be practicing that as first years because it's tough to get good at, [4] so why not start early?

[1] "totally ignore what i said the first time" - So, i didn't say to "TOTALLY" ignore; only to ignore the "Try to focus your HPI using the relevant ROS section", as I really don't think a first year, who appears to be doing a system based curriculum, will have enough background to pick out what is pertinent and what is not, especially if they haven't finished all of the systems. Even in your own example of Abdominal Pain, where you state that the relevant systems to ask about are GI, GU and Repro. What about General/Constitutional, Psych, Skin, Vascular, HEENT systems which all are associated with various conditions that can result in abdominal pain...which a first year would most likely not know.

[2] "Verbally blow the resident...almost exactly the same advice I gave to the OP" - So, "I agreed for the most part" with Bacchus concerning the use of blanket statements and that they can be dangerous to use, which i gave an example of when it has bitten me in the past [granted, not with ROS] and also pointed out that I don't think it is possible to interview patients (more specifically timed standardized patient encounters) without using blanket statements. The only thing you said that was similar to Bacchus's statement was to use your ROS to guide the rest of your exam. Which, going back to #1, I said to ignore "using Relevant ROS section".

[3] "Is that so hard?" - apparently it is if the only systems that concern you for Abdominal Pain are GI, GU and Repro.

[4] "So why not start early?" - The OP is worried about losing points on his standardized patients. It's probably not a good idea to start guessing what is pertinent and what is not when you are already losing points and are worried about it.

 

[benzonase]

I've noticed my school focuses a lot more on physical exam skills for the first year rather than history taking.

Is that bad? =\

I should say I've had about 2 experiences writing notes after interviewing standardized patients. Whereas almost every week we've had labs to learn relevant physical exams for what organ/system block we've covered.

 

[Bacchus]

I've noticed my school focuses a lot more on physical exam skills for the first year rather than history taking.

Is that bad? =\

I should say I've had about 2 experiences writing notes after interviewing standardized patients. Whereas almost every week we've had labs to learn relevant physical exams for what organ/system block we've covered.

You don't really learn how to take a history until you're doing rotations and then you'll learn quickly you still don't do a very good job... usually pointed out by a resident or attending having a bad day. Don't sweat it.

[tongue in cheek]don't worry about the PE either since we radiate everyone. When I was on neuro we always had preliminary imaging before seeing the patient. The diagnosis was made, we were just doing an exam to show the manifestations. Granted, TIME IS BRAIN.

 

[TooMuchResearch]

You don't really learn how to take a history until you're doing rotations and then you'll learn quickly you still don't do a very good job... usually pointed out by a resident or attending having a bad day. Don't sweat it.

[tongue in cheek]don't worry about the PE either since we radiate everyone. When I was on neuro we always had preliminary imaging before seeing the patient. The diagnosis was made, we were just doing an exam to show the manifestations. Granted, TIME IS BRAIN.

Time is brain is certainly the slogan, but the data don't actually show this. Not that I'm advocating for a more thorough neuro exam.

 

[evilbooyaa]

Time is brain is certainly the slogan, but the data don't actually show this. Not that I'm advocating for a more thorough neuro exam.

Thank god. I am dreading the first day of the 'stroke' part of my neuro rotation, where we will play 'localize the lesion', and I will fail so alarmingly stupidly that I will just get wide-eyed looks from the residents, attendings, hell even the other medical students.

 

[TooMuchResearch]

Thank god. I am dreading the first day of the 'stroke' part of my neuro rotation, where we will play 'localize the lesion', and I will fail so alarmingly stupidly that I will just get wide-eyed looks from the residents, attendings, hell even the other medical students.

The correct answer is "lets review the imaging."

 

[mvenus929]

The correct answer is "lets review the imaging."

Unless you had my neuro attending, who insisted we localize the lesion by exam even when we had imaging.