Properly documenting the history of a patient’s chief complaint
New patients have their own unique needs and you have some detective work to do. Whether in the patient’s hand on the intake form or yours as you conduct a patient interview, you need to record the answers to the many questions you have about the complaint, which brings them in.
There are important details to be gathered – facts which will establish a baseline and influence your choice of physical examination procedures and your decisions regarding their case.
There are some very good reasons to ask your patient particular questions about their chief complaint.
Onset – Has it arisen as the result of a specific incident, or for no particular reason at all? We need to know why a patient is suffering. We want to identify the cause, if we can. The presence of precipitating factors can make this easy; insidious onset can indicate something more ominous.
Location – Can the source of the pain be localized? The more superficial the source, the more it can be precisely pointed to. This is certainly the case when a patient complains of chest pain. Heart and lung and mediastinal conditions are likely to be hard to point to directly, unlike a subluxated rib.
Duration and Frequency – A one-time, acute onset condition is usually much more straightforward than cases where symptoms are chronic with acute flare-ups. You need to ask very clear questions if you are to sort out any useful patterns that might help resolve their problems
Radiations – Any symptoms “spreading” from another source must be examined more closely. Pain is the most common symptom to radiate but numbness, tingling, coldness and weakness can also be sensed traveling down the back of the leg or into the shoulder blade, for example.
Patterns of trigger point and sclerotomal referral are what we commonly see in practice, but we all need to be familiar with patterns of radiation which can indicate more serious pathology – a sharp pain that stabs behind the collar bone can be a sign of peritonitis; an electrical, gnawing pain that hits the centre of the left palm could be a symptom of a heart attack.
Intensity – This question is often answered with a number from one through 10. It is also useful to frame a query about intensity in terms of what it is preventing them from doing. It is critical that these facts be documented if you ever want to prove that what you do works.
Characteristics – There is a big difference between a patient describing their symptoms as “tension” or “stiffness” and a patient who is using words like “agony” or “gnawing” or “electrical.” In the quest to figure out how to help your patients, make sure you pay attention to their language so that you can be clear about what’s causing their suffering.
Aggravating and Relieving Factors – The answers to these questions are very important when we are determining if a patient’s complaint is mechanical or pathological. Mechanical/neuromusculoskeletal conditions that we help with so much have clear patterns of symptoms made worse and better by particular positions or treatments. Cases where there is no clear pattern, where you cannot seem to identify functional components, are potentially a pathology that needs to be assessed by another type of specialist.
Associated Symptoms – By asking about other symptoms, we are investigating the possibility that there is some constitutional or systemic problem. We are also looking for potential patterns of compensational dysfunction with their biomechanics.
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It is recommended that you make use of a mnemonic device to ensure that ALL the necessary questions about their chief complaint are asked and answered.
One popular one is SOCRATES (Site, Onset, Character, Radiations, Associated symptoms, Time course, Exacerbating/Relieving factors, Severity). Another is OLDRFICARA (Onset, Location, Duration, Radiations, Frequency, Intensity, Character, Aggravation, Relief and Associated symptoms).
We tend to pay more attention to all of these details when the patient is new, but you still need to ask all of these questions to a regular patient with a new complaint.
One of the most important requirements of a patient’s subjective reporting is to be specific. You could write down that the patient has “knee pain,” or you could note that they have “sharp, intermittent pain localized to the medial aspect of the tibial plateau which is worsened by yoga and better with cold.”
The history of a chief complaint provides valuable clues to the patient’s condition. Figuring out both cause and cure for your patients depends on your ability to collect and document all of the necessary facts.
DR. DAWN ARMSTRONG is a graduate of CMCC and has been in practice for over 30 years. She is currently focused on promoting life-long learning and professional development and has created a continuing education course – Clinical Record Keeping: A Hands-On Approach. Learn more at auroraeducationservices.ca.
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