What does a 'focused' history taking and physical mean?

I received the following email from an OSCE candidate and would like to share it with you:

Dear Dr Al lmari,

I am still confused regarding Focused physical examination.

I need your guidance for 5 min, 8 min stations.

I read it from your notes that it is not a head to toe examination.

But still not getting it, Could you please guide me.

Is it

1.        .   To focus on Only the system asked to exam as per chief complaint e.g CVS, Respiratory etc.  OR
2.       .    Do physical as per differential + focused examination of system asked as per Chief complaint.

For example

1.        .   in case of patient with cough, Face, Neck, LN & Respiratory System + Upper Abd ( GERD) or Only Respiratory ( Chest Only)   or only Chest
2.       .    In case of Fluid Assessment CHF pt- BP, JVP, Kausalmaul, hepatojuglar reflux, CVS( Ins, Pal, Ausculation) +  Vessels-Radial, + Carotid, Aorta, Renal & Illac for Bruit, + Popletial, Post Tibial and Dorsalis pedis,  Edema over leg, crepts on base of lungs and Abdominat Girth, Ascites

Am I right ? Sir please guide me. Thanks for your time.

With Best Regards

-------------------------

Hello Dr ....,

Sorry for the delay of my reply.

You are right its somehow confusing what a focused approach is.

Basically, the shorter available time is, the more focused you should be.

But focused on what? You should be focused on the differential diagnosis (DDx) of the chief complaint, not the system.

Your focus is on developing a differential diagnosis specific for this patient with your first guess is the best match followed by less matching DDx.

If you noticed, OSCEhome flow charts’ questions box for each system does cover all the required differentials for any chief complaint from other systems.

For example, the first few system specific questions box for chest pain are similar in cardiology and respiratology and even GI.

Meaning after asking these few questions you will know that you are dealing with a cardiac, respiratory, GI, or MSK case and proceed with questions of that system specific questions/examination box.

Similarly, questions for each symptom, e.g cough, are identical in any system specific questions box.

However, if you thoroughly practice our flow charts, you will be fast to ask and do more than needed if you are not sure.

This will assure checking all the required check marks to be on the save side.

The main logic of the OSCEhome Systematic Approach to the OSCE and clinical patient encounters is to eliminate burden of focusing on WHAT to ask or do, HOW to ask or do, and WHEN to ask or do and redirect your attention and thinking to focus on developing a specific DDx for this patient, to build rapport with the patient and a plan to proceed,

In answering your questions:

Is it

1.         .  To focus on Only the system asked to exam as per chief complaint e.g CVS, Respiratory etc.  OR
2.         .  Do physical as per differential + focused examination of system asked as per Chief complaint.

By using the OSCEhome flowchart for history taking, you do have now a DDx.

Next, for examination select the system specific box that match your first DDx.

Similar to questions boxes, OSCEhome examination flow charts do cover related symptom/sign DDx.

Meaning your above #2 answer is the way to go.

1.         .  in case of patient with cough: Face, Neck, LN & Respiratory System + Upper Abd ( GERD) or Only Respiratory ( Chest Only)   or only Chest
2.        .    In case of Fluid Assessment CHF pt- BP, JVP, Kausalmaul, hepatojuglar reflux, CVS( Ins, Pal, Auscultation) +  Vessels-Radial, + Carotid, Aorta, Renal & Illiac for Bruit, + Popletial, Post Tibial and Dorsalis pedis,  Edema over leg, crepitus on base of lungs and Abdominal Girth, Ascites

1- If you look at the OSCEhome questions set for cough in all system specific questions boxes you will find them identical and by asking them you will know which system specific examination box to follow.

(Note: Face and neck in cough cases are for upper respiratory causes which is already covered in chest examination box).

2- For CHF, the cardiac specific examination box cover all these.

Hope this answers your questions.

All the best for your OSCE preparation.

Have a nice day.

Al
www.oscehome.com