Osce

Front 1

Chief Complaint questions

Back 1

- What brings you to the office today?
- What health concerns do you have today?
- What can I do for you today?

Front 2

History of present illness: CLODIERRSSS

Back 2

- C: Character - What is the sensation?
- L: Location - Point with one finger to where
- O: Onset - When did it start?
- D: Duration - How long? Chronic or acute?
- I: Intensity - How bad? 1-10?
- E: Exacerbation - What makes it worse?
- R: Remission - What makes it better?
- R: Radiation - Does the pain go anywhere else?
- S: Social Impact - Has it affected your social life?
- S: Setting - Where does it occur?
- S: Symptoms - What symptoms are associated?

Front 3

Past Medical History

Back 3

- Hospitalizations - Reason, dates, therapy?
- Surgeries - Reason, dates, complications

- Injuries/Accidents - lacerations, unconsciousness, fractures, penetrating wounds?
- Major Illnesses - Hypertension, coronary artery disease, chronic obstructive pulmonary disease, tuberculosis, diabetes?
- Obstetrics/Gynecology -
- Menarche
- Frequency of periods?
- Length and heaviness of flow of periods
13 X 28 x 4 (moderate)
- First day of your last period?
- Have you ever been pregnant?
- How many times?
- How many of those pregnancies resulted in live births?
- How many of those pregnancies were post term or pre term?

- Stillborn births?

- Any abortions, spontaneous or induced?

- What type of delivery?
- Any problems with your pregnancies or births? Were they resolved?

- Psychiatric - Have you ever seen a counselor or a psychiatrist? Have you ever been hospitalized for emotional reasons? Have you ever taken medications for any psychiatric or mood disorders?
- Transfusions - Number dates, reason, possible reactions?

Front 4

Current Medications

Back 4

- Do you take any prescription medication?
- Over-the-counter drugs?

- Topical drugs, applied to skin?
- Vitamins or minerals
- Borrowed medications
- Herbal teas or botanicals

- Home remedies
- Any diet supplements?

Front 5

Allergies

Back 5

- Medication
- Seasonal/Environmental
- Food

If allergic to anything, when did it begin, what happens when you take it?

Front 6

Major Medical problems, family history

Back 6

I will now list about 13 different diseases, after I say each one, I want you to say yes if anyone in your family has it and no if no no one has it. Okay, ready?
- Heart disease
- Stroke
- Hypertension
- Diabetes

- Mental illness
- Substance abuse
- High Cholesterol
- Cancer, what type?

- Thyroid disease
- Tuberculosis
- Sickle cell disease or trait
- Asthma or allergies
- Arthritis

Front 7

Family History

Back 7

Blood Relatives: Grandparents, parents, siblings and children
- For each living person, list gender, age and major medical problems, including psychiatric symptoms. Ask about genetic predispositions, communicable diseases and other conditions that the patient may have gotten from family members.
- For each deceased, list gender, age at death and reason for death - use empathetic responses when patients tell you about deaths in the family.

Front 8

Current health/risk factors

Back 8

A) Exercise
- Do you engage in regular exercise?
- Gym?
- About how many flights of stairs could you climb before getting worn out?
B) Nutrition
- How are your eating habits?
- Do you limit any specific macronutrient? Fats, carbs, protein?
- Generally any diet restriction?
- For women: Do you get enough calcium?
C) Smoking
- Have you ever used tobacco? Cigarettes, Cigars, pipe, chew or snuff? Amount? Duration?
- Have you used tobacco in the past?

- Second hand smoke?
- If smoking: would you like to quit?

- Have you tried to quit before?
D) Alcohol

- During an average week, how much alcohol do you drink?
CAGE: Cut down? Annoyed? Guilt? Eye-opener?
- What do you drink? beer, wine or hard liquor?

- Do people in your family drink?

- Do you ever drink and drive?
E) Other drug use

- Any recreational drugs? Weed, hallucinogens, cocaine, heroin, opioids, pain killers, steroids?
- Ever shared needles?
- Have you tried to quit? Do you want to quit?
F) Sleep pattern
- Do you usually wake up in the middle of the night?
- If so, do you fall back asleep?
- Do you snore or stop breathing?
J) Recent health exams
- Up to date on your physicals?
H) Immunizations

- Up to date on your Immunizations?
I) Injury prevention
- Do you wear a seatbelt?
- Smoke detector in your home?
- Firearms in the house? stored in a safe area?
J) Chemoprophylaxis
- Multivitamin?

Front 9

Social History

Back 9

A) Personal Status

- Birth date and place?
- Upbringing - Parents divorced or together?
- Ethnicity?
- Education?
- Marital status? - # of times married and for how long?
- Children?
- What do you do for fun?
- What are your sources of stress?
- Would you say you are satisfied with life?
B) Culture and Religion
- Very generally, how would you identify your religion and culture?

- Would you say your religion or culture inhibit you ability to seek medical care?

C) Support System
- Would you say you have a good social support system? Friends, family, community?
D) Socioeconomic Data
- Do you live in an apartment or home?
- Do you have health insurance? HMO or PPO?
- What is your means of transportation?
- Do you feel as though you have good job security?

E) Domestic Violence
- Do you feel as though anyone you have a relationship with ever hurts you?
- Do you feel as though anyone you have a relationship with isolates you?
- Do they ever scream at you? How often? 1-5?
- Do they ever threaten you? How often?
- Do they ever insult you? How often?
- Do they ever physically harm you? How often?
F) Occupation
- What do you do?
- How long?
- Are you exposed to any harmful materials at work? (Lead, arsenic, chromium, asbestos?)
G) Sexual Behavior
- How old were you when you had your first sexual experience?
- Sex with men, women or both?
- Vaginal, oral or anal or a combonation?

- Have you been tested for STDs?
- Any forms of contraception?
- Have you ever felt sexually abused?
H) Military
- Any military experience? When, where?
I) Travel

- Have you traveled outside of the US to places that have exposure to contagious diseases? When? For how long?

Front 10

Patient's Perspective

Back 10

E - Explanation

- How was your overall health before this problem?
- What do you think is causing this issue(s)?
- Have you had this kind of problem before?
- Do you know anyone else with this issue?
- What are the main difficulties this condition has caused you?
- How do you cope?
- What is your biggest fear?

T- Treatment
- Do you do anything to treat this disease?
- What kind of treatment do you think will help?
H - Healers
- Who have you consulted about this issue other than me? Friends? Spiritual healers? family? Alternative health providers?
- Did they give you any advice? If so, what was it?