Guerilla Clinic Basics – Taking a Patient History in a Clinic or Sick Visit Setting, by Teddy Bear (D.O.)
David Caldwell Log Cabin School – Virtual
Teddy Bear holds a Doctor of Osteopathy (D.O.) degree, and practices medicine as a general practitioner. As a hobby, Teddy collects various state’s medical licenses. Having entered medical school specifically with a coming collapse in mind, Teddy appreciates the opportunity to educate, viewing it as a form of caching. Teddy Bear trains to protect the innocent from monsters when the lights go out, and hopes you do, too.
Taking a patient history in a clinic or sick visit setting: (ID, Source, CC, HPI, ROS, PMH, PSH, FH, Soc H, Meds, Allerg,)
What separates human medicine from veterinary care is that humans are usually able to talk to us. This allows us to gather information about whatever is the immediate issue, but also contextualize that issue with details of the patient’s life and circumstances. Like vitals, we should be making a record of the information that we gather, both for the benefit of our own thought process as well as including others in patient care. If you’re anything like me, it’s amazing how much less you recall of small details compared to what you think you’ll be able to remember. Let’s dive in.
For your chart, you need some kind of identifying information such as name/initials and a date of birth. You should also note whether the source of your history is the patient, someone else, or some form of chart.
Chief Complaint (CC)
CC is whatever brings the patient to you right now, stated as single simple sentence or phrase. Example, “stomach hurts”, “head hurts”, “fell out of tree”, “shot in the leg”, etc. This should preferably be in the patient’s own words.
History of Present Illness (HPI)
This is where we explore the chief complaint, asking questions that will expand our understanding of it. There are multiple acronyms used as mnemonic devices for this. I was taught OPQRST, but another is OLD CARTS. For OPQRST, note that there are multiple words to each letter, so it is more accurately OOPPPPQQRRST.
OPQRST
Onset and Origin: When did you first notice symptoms? What was going on when you first noticed symptoms?
Prior, Progression, Palliative, and Provoking: Have you had something like this before? If so, when? Is this episode been getting better, worse, or staying the same since it started? What makes it better? What makes it worse?
Region and Radiation: Where is the symptom located on or in your body? Does go anywhere else on or in your body?
Severity or Scale: When the symptom is pain, this is often graded on a scale of 0 to 10, with 0 being nothing and 10 being the worst pain a patient has ever felt. 1 to 4 are mild-moderate pain, 5 to 7 being significant pain, and 8 to 10 being severe pain. Other symptoms are not so easy to grade, but one way is to ask how disruptive to their day the symptoms are. Examples: Is your memory problem interfering with daily routine? Is dizziness keeping you from functioning? Is diarrhea keeping you no further than 10 feet from the toilet?
Treatments: What have you tried so far to help with this problem? Has it helped?
OLD CARTS
Onset
Location: this is analogous to Region
Duration: How long has this been going on?
Character: Quality, Severity
Aggravating or Alleviating factors: same as Palliative and Provoking
Radiation
Timing: Onset
Setting: Origin
As you can see, either of these mnemonic tools will help you get the larger story of chief complaint. Pick one and practice it.
Review of Systems (ROS)
This is a brief survey of all the patient’s organ systems to make sure there is not something they didn’t think to mention that may be relevant. This is largely taken from the book Bate’s Pocket Guide to Physical Examination and History Taking with some modifications per personal experience and education.
Asking questions for every system is not usually a productive use of time. Ask the questions for the system or systems pertinent to the patient’s chief complaint and HPI. Some questions are repeated in multiple systems due to being pertinent in each of those systems.
Exhaustive ROS:
General: Usual weight, recent weight changes, clothing fitting differently; weakness, fatigue, fever or chills
Skin: Rashes, lumps, sores, itching, dryness, color change (paleness, redness, yellowing/jaundice); hair or nail changes; changes in size or color of moles
Head, Eyes, Ears, Nose, Throat (HEENT):
- Head: headache, injury, dizziness (room spinning), light-headedness (feeling of about to pass out)
- Eyes: Vision changes, glasses or contacts, pain, redness, tearing, double or blurred vision, spots, specks, flashing lights, glare
- Ears: Hearing, tinnitus, vertigo, earache, or drainage
- Nose and sinuses: Frequent colds, nasal stuffiness, runny nose, discharge or itching, hay fever/allergies, nosebleeds, sinus trouble
- Throat (or mouth and pharynx): tooth or gum problems, bleeding gums, dentures, sore tongue, dry mouth, frequent sore throats, hoarseness, difficulty swallowing, painful swallowing, bad breath, difficulty with speech
Neck: Lumps, swollen glands, goiter, pain, stiffness
Breasts: Lumps, pain or discomfort, nipple discharge, changes in skin appearance, nipple inversion
Respiratory: Cough, sputum (color, quantity), coughing up blood (hemoptysis), shortness of breath (dyspnea) with or without exertion, wheezing, pain with breathing, changes in sounds of breathing, snoring, temporary cessation of breathing (apnea)
Cardiovascular: chest pain or pressure, rapid heart beats or a feeling of the heart beating out of the chest (palpitations), dyspnea, shortness of breath lying flat (orthopnea), sleep apnea, swelling (edema) especially in lower legs
Gastrointestinal:
- Esophageal and stomach: Heartburn, change in appetite, nausea, throwing up blood (hematochezia), excessive belching
- Intestinal: Bowel movements, changes in color or size of stools, rectal bleeding or dark tarry stools, hemorrhoids, constipation, diarrhea, bowel incontinence, abdominal pain, food intolerance, excessive passing gas
Peripheral vascular: one hand or foot colder or paler than the other, leg cramps when walking, swelling in calves, legs, or feet with redness, warmth, or tenderness; color changes in fingertips or toes in cold weather
Urinary: frequent urination, making a lot of urine (polyuria), urgency, burning or pain on urination, blood in urine (hematuria), urinary incontinence.
Genital:
- Male: Hernias, penile discharge or sores, testicular pain or masses, difficulty with erections
- Female:
- Menstrual: Menstrual regularity, frequency, duration; amount of bleeding (number of pads/tampons in a 24 hour period), bleeding between periods or after intercourse; excessive cramping before or during periods (to the point of interrupting daily activities).
- Vaginal: Discharge, itching, sores, or lumps
Musculoskeletal: Muscle or joint pain, stiffness, backache. Neck or low back pain. Joint pain with systemic features such as fever, chills, rash, anorexia (loss of appetite), weight loss, or weakness.
- If present, describe location of affected joints or muscles, any swelling, redness, pain, tenderness, stiffness, weakness, or limitation of motion or activity; include timing of symptoms (e.g. morning or evening), duration, and any history of trauma.
Psychiatric: Nervousness, tension/anxiety; mood including depression, memory changes, changes in insight or judgment
Neurologic: Changes in attention or speech; changes in orientation or memory; headache, dizziness, vertigo (room spinning); fainting, blackouts, seizures, weakness, paralysis, numbness or loss of sensation, tingling or “pins and needles,” tremors or other involuntary movements.
Hematologic: easy bruising or bleeding, pallor (paleness), yellowing/jaundice.
Endocrine: Heat or cold intolerance, excessive sweating, excessive thirst or hunger, polyuria
My condensed ROS goes something like this.
Condensed ROS (developed by personal habit):
General: Fatigue or low energy (malaise), changes in weight; fever or chills
Skin: New rashes, marks, lumps, bumps or bruises? Any rapidly changes moles or marks?
HEENT: Hair changes, bald spots, headaches, tooth or gum problems, neck stiffness, vision changes, light or sound sensitivity, eye, ear o