Focused History or Exam

What is a “Focused” History or Exam?

OSCE instructions often refer to taking a “focused” history or physical examination.  How much information should be gathered for a focused history or examination, and how does this differ from a “comprehensive” history and physical examination?

Almost all OSCE stations are set up to take a history or do a physical examination in a time frame of between 8 to 14 minutes.  This is very similar to examining patients in an ambulatory setting – a doctor’s office, a clinic, an emergency room.  OSCEs simulate real visits in which you, the examiner, are meeting the patient for the first time, without previous knowledge of the patient or access to a medical record.  

A “focused” history and examination is one that can be taken in 8 to 14 minutes that addresses the patient’s presenting health issue.   The “focused” history should explore and characterize the patient’s main health concern but must also include critical background history that is necessary to put the patient in context.  A “focused” physical examination consists of selected items that help confirm or refute physical findings related to the presenting health issue.  

A “Focused” history:
  • Chief Complaint
  • History of Presenting Complaint (OPQRST etc.)
  • Critical Background History:
    • Other current health problems
    • Past medical history
    • Medications & Allergies
    • Pertinent family history
    • Significant risk factors
    • Social – such as occupation or support issues
    • ROS items pertinent to the CC
A “Focused” Physical Examination -  Think about what you need to do to confirm or refute your hypothesis.  Also think about what other physical findings might be associated with your patient’s issue(s).  

Example: Hypertension
  • Take Blood Pressure
  • Check fundus for AV nicking or other changes associated with hypertension
  • Listen to heart  (4 places on skin)
  • Listen to lungs  (at least 3 levels each side on skin)
  • Check carotid pulses & listen for bruits
  • Check peripheral pulses
  • Examine abdomen for renal bruits and aortic aneurysm
REMEMBER
*  You do not need to go into each item of critical background history in great detail, but you should briefly touch on each item or at least consider them.  This can be done relatively quickly if you have the items in you mind, and ask general questions.

Example:  Do you have any other health issues?

 

  • How has your health been in the past? Hospitalizations or operations?
  • Are you taking any medications?  Are you allergic to anything?
  • Anyone else in the family sick?  OR Any family health issues?
  • Are you a smoker?  alcohol?  lifestyle risk factors?
  • What kind of work do you do?  Do you have some help at home?
  • (ROS Depending on CC) Any fever?  Breathing problems? etc.  
*  When selecting physical examination, think about what a prudent physician might check in an ambulatory setting to confirm or refute your hypothesis and collect any unexpected findings.

Example:  RUQ pain – you suspect gallstones.
  • Listen to Heart and Lungs    (on skin, in appropriate locations)
  • Have pt show area of pain – inspect, auscultate or palpate as appropriate
  • Do abdominal exam (inspect, auscultate, percuss & palpate)
    • Murphy’s maneuver
  • Check for CVA tenderness

 

What is a “Comprehensive” History and Physical Examination?

A “comprehensive” history and physical examination is one that reviews most if not all history in the patient, and does a head to toe physical examination.  It is usually done in one of two circumstances:  1) The inpatient admission history and physical examination.  2) In a doctor’s office or clinic when the patient establishes care, or gets a periodic complete history and physical exam checkup or a periodic health maintenance examination.   A “Welcome to Medicare” examination is one example of a “comprehensive” history and physical examination. 

Because most comprehensive history and physical examinations take between 30 to 60 minutes to complete, they are rarely tested in their entirety in OSCE formats.