Why Social History Is So Heavily Marked
Social history is examined in nearly every OSCE history-taking station — and candidates consistently underperform on it. Examiners report that students ask about smoking, miss occupation, and skip housing, functional status, and support networks entirely. A thorough social history contextualises the clinical diagnosis, guides management, and influences discharge planning. It is one of the easiest sections to score maximum marks on with a systematic framework.
The SADMA Framework
Use SADMA as a mnemonic for the core social history domains:
| Letter | Domain |
|---|---|
| S | Smoking |
| A | Alcohol |
| D | Drugs (recreational) |
| M | Medications (including OTC and herbal) |
| A | Allergies (and nature of reaction) |
Each domain has sub-questions:
Smoking: current/ex/never; pack-year history (packs per day × years smoked); type (cigarettes, vaping, shisha); cessation advice offered?
Alcohol: units per week (1 unit = 10ml ethanol); CAGE questionnaire (Cut down, Annoyed, Guilty, Eye-opener); binge drinking pattern; dependence features (tremor, sweats, seizure risk on withdrawal)
Drugs: recreational drugs (type, route, frequency); needle sharing (BBV risk); legal highs
Occupation and Work History
Always ask:
- Current job and specific work tasks (not just job title — a "nurse" may be a ward nurse or work in a call centre)
- Sick leave history and impact of illness on work
- Occupational exposures: asbestos (mesothelioma), silica (silicosis), coal dust, isocyanates (occupational asthma), chemicals, noise (hearing loss)
- Shift work (affects sleep, medication timing)
- Driving occupational requirement (relevant to DVLA discussions, seizures, visual acuity)
💡 Tip
In respiratory stations, asking about occupation is mandatory — occupational asthma, COPD from dust, and mesothelioma from asbestos exposure are frequently missed without this question.
Housing and Home Situation
- Who does the patient live with? (alone = safeguarding risk in elderly or mentally unwell)
- Type of housing: house, flat, sheltered accommodation, care home
- Stairs: can they manage stairs? Is the bedroom upstairs?
- Adaptations: handrails, walk-in shower, commode, hospital bed
- Relevant for discharge planning: will they cope at home?
Functional Status and IADL
Activities of Daily Living (ADL): washing, dressing, grooming, toileting, feeding, transferring
Instrumental ADL (IADL): cooking, shopping, managing finances, using the phone, transport, managing medications
⚠️ Red Flag
For elderly, frail, or post-operative patients, IADL assessment is a core component — failing to ask about it loses significant marks in frailty, geriatric, and discharge planning stations.
Travel History
- Recent travel (within the last 3 months): destination, duration
- Relevant for infectious diseases: malaria prophylaxis, hepatitis exposure, TB areas
- Vaccinations for travel
- Sexual contacts abroad
Support Network and Carers
- Family support: who visits, who provides care
- Formal care: home carers (how often), district nurses, meals on wheels
- Carer burden: is the carer coping? (relevant in dementia, chronic illness)
Mark Scheme Checklist
- ✓Smoking (status, pack-years, cessation offered)
- ✓Alcohol (units/week, CAGE, dependence features)
- ✓Recreational drugs
- ✓Medications and allergies
- ✓Occupation and exposures
- ✓Housing (type, who with, stairs)
- ✓Functional status (ADL and IADL)
- ✓Support network and carers
- ✓Travel history (where relevant)
Frequently Asked Questions
"What is the SADMA framework and why should I use it in every OSCE history?"
SADMA is a mnemonic covering the five core social history domains: Smoking, Alcohol, Drugs, Medications, and Allergies. Using it systematically prevents the most common social history error — asking about smoking but missing alcohol dependence, recreational drugs, or allergy details. In an OSCE, mentioning each domain by name as you move through it ("I'm now going to ask about your social history — starting with smoking…") shows structure and gains marks for organisation. The framework takes under 90 seconds to run through when compressed, and the questions it generates are disproportionately mark-heavy.
"How do you calculate pack-years and why does it matter in an OSCE?"
Pack-years = number of packs smoked per day × number of years smoking, where 1 pack = 20 cigarettes. A patient who smoked 20 cigarettes per day for 30 years has 30 pack-years; one who smoked 40 per day for 20 years also has 40 pack-years. Pack-year history is clinically important because COPD risk rises significantly above 20 pack-years, lung cancer risk is substantially elevated above 30 pack-years, and spirometry referral thresholds use pack-year history. In a respiratory OSCE, a candidate who quantifies pack-years rather than just noting "smoker" demonstrates clinical thinking and scores higher on the clinical reasoning domain.
"What occupational exposures must you always ask about in respiratory and other OSCE histories?"
The highest-yield occupational exposures are: asbestos (carpenters, plumbers, shipbuilders, insulation workers → mesothelioma and asbestosis), isocyanates in spray paint and varnish (occupational asthma), coal and silica dust (pneumoconiosis, silicosis), grain and flour dust (baker's asthma), bird keeping (extrinsic allergic alveolitis/hypersensitivity pneumonitis), and cotton dust (byssinosis). In haematology stations, ask about benzene exposure (leukaemia) and ionising radiation. The question "Tell me about your job — what does a typical working day involve?" reveals far more than "What is your job?" alone.
"Why is functional status so important in OSCE history taking for elderly patients?"
Functional status — particularly the ability to manage activities of daily living (ADL) and instrumental ADL (IADL) — directly determines discharge planning, rehabilitation needs, and safeguarding requirements. A patient who cannot cook, shop, or manage medications independently cannot safely go home without a package of care. In OSCE stations involving elderly patients, frailty assessment, or discharge planning, candidates who skip IADL assessment consistently lose marks in the clinical reasoning and patient management domains. Always ask: "Before this admission, were you managing everything at home by yourself, or were you getting any help?"
"What is the CAGE questionnaire and when should you use it in an OSCE?"
CAGE is a 4-item validated alcohol screening tool: C — Have you ever felt you should Cut down on drinking? A — Have people Annoyed you by criticising your drinking? G — Have you ever felt Guilty about drinking? E — Have you ever had a drink first thing in the morning as an Eye-opener? Two or more positive answers indicates probable alcohol use disorder with high sensitivity. Use CAGE whenever alcohol misuse is a possibility — not just in obvious cases. In an OSCE, if you suspect dependence, also ask about withdrawal symptoms (tremors, sweats, seizures) as alcohol withdrawal is life-threatening and affects inpatient management.
"When should travel history be included in an OSCE social history?"
Travel history should be asked in any presentation where infectious disease is in the differential: fever, diarrhoea, jaundice, rash, lymphadenopathy, pneumonia in a returned traveller, or weight loss with night sweats. Key questions: destination (within the last 3 months — malaria can present months after return), duration, activities (fresh water exposure → schistosomiasis; rural areas → rabies risk), prophylaxis taken, vaccinations, and sexual contacts abroad. In a febrile returning traveller, a candidate who does not ask travel history will miss malaria, typhoid, dengue, and viral haemorrhagic fever in the differential — a critical omission.
Related guides: Drug History OSCE · Alcohol History and Brief Intervention OSCE · Frailty Assessment OSCE · Discharge Planning OSCE · How to Take an Abdominal History OSCE