OSCE – History Taking

1. Travel History

Subject and Curriculum Reference

Communication

History taking

Infections in the returned traveller

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Clinical Scenario Stem

You are a consultant on shift in an urban emergency department on a Thursday afternoon. You have been asked to see Mr. John Clark a 24 year old man who has presented with fevers. He has recently been travelling in South East Asia.

In the next room is John Clark. You are to see him and take a history from him. At the end of the consultation you are to explain to Mr. Clark what your differential diagnosis is and what your management and diagnostic plan is.

The patient, Mr. John Clark is present in the next room.

There will be no interaction with the examiners in the room.

 

Patient Instructions 

The character

Mr. John Clark is a 24 year old man who has just returned home from 3 months back-packing in South East Asia and has presented to the emergency department today sick with fevers.

Mr. John Clark is a fully-qualified taxation accountant who finished university 2 years ago and has since been working for the Australian Taxation Office. He has taken leave for 6 months from his job to go travelling and has spent the last 3 months back-packing through South East Asia.

He spent the first 2 months travelling through Thailand, Cambodia, Vietnam and Laos. He started on the southern coast in Thailand and then worked his way north to northern Thailand then across to Laos, down into Cambodia and then into Vietnam. He has been in cities, small coastal communities and in small villages.  He has stayed in cheap back-packer accommodation.

He then flew to Indonesia and has spent the last month surfing with friend in Lombok. In Lombok he has also stayed in a cheap back-packers on the beach.

He did see his GP before he went and got some immunisations. He thinks he got one for Hepatitis A but cannot remember what the other needles were for. He did not bring the vaccination book that was given to him. He was also prescribed some anti-malarial tablets to take and took them for the first 10 days but they gave him tummy pain so he stopped.

He did try to be a bit careful with mosquitoes by using mosquito repellent and slept with a mosquito net.

He was well when he was overseas except for one day of diarrhoea and vomiting 6 weeks ago in Vietnam.

He did have sexual encounters with women whilst overseas but tried to be careful and used condoms. He did not have any piercings or tattoos done whilst overseas.

He returned home 3 days ago for his sister’s wedding (in a week) and then has a flight booked back to Indonesia. He plans to spend the next 3 months travelling through Indonesia.

The only medical history is that he had appendicitis and had his appendix removed when he was 16. He takes no medication and has no allergies.

He was living with a friend but has moved out of his rented room to travel.

He is currently staying with his parents. He has 2 sisters, both older. There is no significant family medical history.

He does not smoke. He does binge drink and does smoke marijuana on occasions. He does not take any other drugs.

 

The scene

2 days ago he started to feel unwell. At first he felt very tired and then got a mild headache. Yesterday he woke with aching muscles and joints and then developed fevers. Last night he spent the whole night shivering in bed and felt very hot. His headache is quite bad this morning and he still has aching muscles and joints. He does not feel like eating but has had no nausea, vomiting or diarrhoea. He does not have a cough and does not have any abdominal pain. He has not pain on urination and does not feel he has to urinate frequently. He does not have any neck stiffness and has not had any periods of confusion. He has had no changes to his vision. He has not had any other symptoms.

 

Specific Instructions

1 minute before the end of the period if the candidate has not volunteered this information already you are to ask “What do you think it is?” and “What tests are you going to do?” and “What is going to happen now?”

 

NB:

  • The “Scenario” in the preceding page is ALL the information provided to the candidate before s/he interacts with the actors.
  • Candidates will only have 7 minutes to try to explain and complete the procedure. Successive candidates will be interrupted by 3-minute breaks, during which the examiners and actor discuss the preceding candidate.
  • After a succession of 10 or less candidates, there is a longer break to permit rest and refreshments

 

Scoring Sheet

Not met Partly met Fully met
Introduction

  • Identification of themselves and patient
  • Clarification of purpose
Structured approach to history taking
Invites and responds to questions from the patient
Detailed history of presenting complaint

  • Onset of symptoms
  • Symptoms
  • Duration
  • Any illness whilst travelling
Travel history – Establishing likely disease exposure

  • When
  • Where
  • Environment i.e. in villages? Cities?
  • Accommodation
Travel History – risky behaviours

  • Sexual history
  • Needle history
    • IVDU
    • Tattoos
    • piercings
Travel history – exposure

  • sick contacts
  • consumption of high risk foods
  • adverse incidents e.g. animal bits/scratches; trauma
Preventative activity

  • pre-travel medical consultation
  • immunisations
  • anti-malarials
Other history

  • past medical and surgical history
  • drug/alcohol history
  • smoking history
  • social history
  • family history
Asks questions clearly, using open and closed questions
Deduces and appropriate differential diagnosis

  • must contain Malaria, Dengue fever and Typhoid
Appropriate diagnostic and management plan

  • involve ID
  • thick and thin smears for malaria
  • Serology for Dengue
  • Blood cultures for Typhoid fevers
  • Disposition likely close follow-up by ID and admission is deteriorates
Must have 4/5 to pass

  • Structured and clear history taking
  • History presenting complaint
  • Detailed travel history
  • Adequate differential diagnosis
  • Appropriate management/diagnostic plan

Author: J Haire 

 

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