Best Clinical History
Introduction
What is the doctor thinking when he obtains the history part of your history and physical. Have you ever wondered?
I present here the pneumonic that Quality physicians have used for coming on 100 years I’ll bet you. It’s nothing I invented.
Disclaimer
The purpose of this presentation is education only. And to let you keep up with your doctor a little bit when you show up sick complaining of something or another. Wink wink.
Obviously, leave the history and physical taking to your physician. She knows what she’s doing.
Some opinion. A lot of history. No pun intended.
Discussion
Questions Doctors Ask When You Are Sick
This is probably the most famous pneumonic that allows a quality clinician to stay focused on the history behind your chief complaint.
“OPQRST“
Onset of symptoms
Persistence
Quality of chief complaint
Radiation
Site – pinpoint or diffuse, back or front
Temporal profile
O. Onset of symptoms. When did this start. Two years ago, two hours ago. Like that. That’s a critical part of the chief complaint. It’s in the first breath, let alone the first sentence, that comes out of the clinician’s mouth when they’re explaining your problem to colleagues, family, and other caregivers.
P. Persistence. Does your symptom wax and wane. Has there been a lucid period where you had no loss of consciousness. Or perhaps a lucid period where the headaches seemed like they had gone away. And now it’s back. Things like that.
Q. Quality of chief complaint. If it’s a pain, is it burning? Is it stabbing? Is it dull? Can you compare it to something to explain how it feels.
R. Radiation. Does the pain in your abdomen radiate to your back? Does the pain in your abdomen radiate to your leg. Does the pain in your chest radiate to your jaw. Radiation, i.e., the projection of your symptom or symptoms, is often a great clue to what sort of malady ails you.
S. Site. Careful description must be made of the site that is affected. Which side of your jaw, what triangular anatomy in your neck landscape… Or, anterior open mouth versus closed mouth while you are clenching, whatever… Or anterior superior midline neck versus posterior inferior neck… Describing exactly where the discomfort is will help care.
T. Temporal profile. Your history has a timeline. Details surrounding this presentation is surely key. I like to ask the patient if they were feeling it last Christmas, last summer. People remember what’s going on around holidays. That’s a nice clue into whether they had or not.
Conclusion
Next time you go to the doctor, see if you can’t keep up with them, with what they’re doing as they go from question to question. See if they’re not following this general guideline for obtaining a really good history that lets them figure out what you might have, that lets them communicate your problem to anybody else that will be involved in your care team.
