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.

PART ONE – TAKING VITALS

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 or nose drainage or bleeds

Neck: Lumps or bumps, stiffness, difficulty swallowing or speaking

Respiratory: Wheezing, coughing, sputum or blood with coughing, difficulty breathing (shortness of breath or dyspnea), pain with breathing

Cardiac: Chest pain, pressure, discomfort or tightness, palpitations

Gastrointestinal (GI): Abdominal pain, heartburn, nausea or vomiting, changes in bowel habits

Genitourinary (GU): Changes in urine, problems with urination, problem with sexual functions, drainage or lesions on the sexual organs

Musculoskeletal (MSK): Abnormally sore muscles or joints, recent traumas, breaks or sprains

Psychiatric: Any new stress, anxiety, nervousness, depression or loss of interest; if so, how it is affecting appetite, sleep, concentration, and energy levels? Any thoughts of self-harm or feeling they would be better off dead?

Neuro: Dizziness, loss of consciousness (LOC), convulsions, numbness, weakness, paralysis, falls, or balance problems

Hematologic: Easy bruising or bleeding

Endocrine: Heat or cold intolerance, polyuria, excessive thirst or hunger

This is still a mouthful, but with practice, you will get the flow of it and will know when to add or subtract from it given clinical context.

If you are truly uncertain what to make of the patient by their chief complaint and/or HPI, or time is of the essence, an ROS should include the following at a minimum.  With practice, this can be elicited from most patients in under 90 seconds. This exact terminology has also been developed by personal habit.

General: Any fevers or chills?

Skin & hematologic: Any rashes, bruises, color changes, or entirely new skin changes?

HEENT: Any dizziness, lightheadedness, headache, vision or hearing changes? Any nasal congestion, runny nose, sore throat, difficulty swallowing?

Respiratory: Any cough or difficulty breathing?

Cardiac: Any chest pain or heart beating out of the chest?

GI: Any change in appetite or nausea, vomiting, or diarrhea?

GU: Any urinary urgency, frequency, or burning with urination?

Musculoskeletal: Any muscle or joint pains?

Neuro: Any numbness, tingling, or weakness in the arms or legs?

Psychiatric: Any anxiety, depression, or thoughts of hurting yourself or anyone else?

Past Medical History (PMH)

First list any childhood illnesses. Then list any adult illness in the following categories:

Medical: date of onset, with any hospitalization dates (example: diabetes, hypertension)

Obstetric/Gynecologic: obstetric history, menstrual history, birth control, and sexual function

• Date of last menstrual period (LMP)
• Number of pregnancies, number and type of deliveries (vaginal vs cesarean), number of abortions (spontaneous and induced [note that in medical terminology, a spontaneous abortion describes the non-operative, spontaneous loss of baby before viability, generally considered 23 weeks into a pregnancy, and is termed a miscarriage if the baby is lost after that 23 week milestone. Not everyone understands this distinction, and using the term abortion may damage your rapport with your patient if she is not familiar with this, and it is your responsibility to protect the relationship while obtaining the relevant information.]). Complications of prior pregnancies.
• Birth control methods, if any
• History of STIs, if any, and treatment status

Psychiatric: illnesses and timeframe, diagnoses, hospitalizations, and treatments

Health maintenance:

Immunizations appropriate for age, exposure to infectious diseases or travel to areas with known infectious diseases such as zika, malaria, polio, etc.

Screening tests as appropriate for age and sex

Past Surgical History (PSH)

Date, facility, reason if known (indication), types of operations (example: appendectomy, tonsillectomy)

Family History (FH)

Any deaths in immediate family (parents, children, or siblings) and why. Any chronic conditions in the immediate family.

Social History (SH)

This is a comprehensive assessment of the patient’s lifestyle and quality of life that may provide valuable insight to specific disease conditions.  Tailor questions appropriate to the chief complaint and HPI, but a minimum should almost always include alcohol, tobacco, and drug use, as these can have immediate bearing on management of an acute problem.

• Significant relationships, social support systems, work history/occupation, education, nutrition (including water sources if in any doubt of access to clean water, raw food intake in any setting, assessing whether food from all food groups is being consumed, and hydration status), exercise, spirituality
• Alcohol, tobacco, illicit drugs including marijuana use
• Sexual history (4 Ps): partners (opposite or same sex), practices (body sites of sexual contact, eg penile-vaginal, oral, anal), protection (specifically whether there is consistent condom usage), past STIs and treatment status, pregnancy plans (some or all of this may be rolled into the OB/gyn history above depending on the patient)

Medications

We want to know any medications or supplements that the patient is taking. We want to Record the name, route, strength, frequency, and reason (indication) for each prescription or over-the-counter (OTC) they are taking. While the most common route is oral (PO) for most medications, others including but not limited to rectal (PR), vaginal (PV), topical (TP), subcutaneous (SC), intramuscular (IM), intravenous (IV), intrathecal (IT), inhaled.

Allergies

We want to record any allergic reactions that the patient has had in the past. Please distinguish these from side effects such as nausea or vomiting. An allergic reaction is a result of a histamine reaction and results in rashes, itching, swelling, wheezing, or anaphylaxis.

Document the agent causing the allergy, the reaction, and the last known date of a reaction.

Concluding thoughts: taking a history from a patient often provides the bulk of the information that you will need to formulate an assessment and plan. It’s common for the format to seem overwhelming, but like anything it gets easier with practice. Fortunately, it is a skill that you can practice at essentially zero cost, as all you might want is a partner to interview and something to write with. The skill of history taking weighs nothing, but means everything.

Financial disclaimer: All provided links are for educational purposes or representational examples only.  At the time of this writing, there are no financial associations with any product mentioned or linked.  All products are examples only without personal knowledge of how they perform, except where noted.