Chief Complaint
Elicit the patient's chief complaint.
History of Presenting Illness (HPI)
Characterize each of the patient's principal symptoms using the OPQRST/OLD CARTS approach
- Method of Injury
- Direction of force
- Joint position
- Articular Pain
- Monoarticular
- Polyarticular
- Pattern of involvement
- Migrating vs. spreading
- Symmetrical vs. asymmetrical
- SEADSS
- S-Symmetry
- E-Erythema
- A-Atrophy
- D-Deformity
- S-Swelling
- S-Skin Changes
- Pain
- Positioning
- Movement vs. rest
- Time of day
- Morning stiffness vs. end of day fatigue
- Quality (see OPQRST/OLD CARTS approach)
- Accompanying Symptoms
- Weakness
- Paresthesia/numbness/hyperalgesia
- Joint instability
- Joint locking
- Joint clicking, grinding, popping
- Loss of function
- Movement limitations
- Non-Articular Pain
- Method of injury
- Direction of injury
- Type of injury (direct impact, concussive force, stabbing, crushing)
- SEADSS
- S-Symmetry
- E-Erythema
- A-Atrophy
- D-Deformity
- S-Swelling
- S-Skin Changes
- Pain
- Positioning
- Movement vs. rest
- Time of day
- Morning stiffness vs. end of day fatigue
- Quality (see OPQRST/OLD CARTS approach)
- Muscle: dull, aching, poorly localized, radiates
- Bone: deep, well-localized
- Nerve: burning, sharp, dermatomal distribution
- Vascular: diffuse, aching, poorly localized, radiates
- Accompanying Symptoms
- Weakness
- Paresthesia/numbness/hyperalgesia
- Loss of function
- Movement limitations
- Axial Pain (Back/Neck)
- Method of injury
- Direction of injury
- Type of injury (Impact, axial force, piercing, crushing)
- Midline vs. Off Midline
- Chronic vs. Acute
- Weakness with fatigue
- Paresthesia/numbness/hyperalgesia
- Saddle Anesthesia
- Bowel incontinence
- Urinary retention
- Gait disturbance
- Trendelenburg gait
- Gluteus maximus lurch
- Foot drop
- Loss of function
- Movement limitations
- Headache
- SEADSS
- S-Symmetry
- E-Erythema
- A-Atrophy
- D-Deformity
- S-Swelling
- S-Skin Changes
- Pain
- Positioning
- Movement vs. rest
- Time of day
- Morning stiffness vs. end of day fatigue
- Qualtiy (see OPQRST/OLD CARTS approach)
Past Medical History (PMHx)
Past medical history:
- Previous trauma, injury, or treatment
- Psoriasis
- Gout
- Cancer
- Menopause
- Osteoporosis
- Rheumatic disorders
- Osteoarthritis
- Rheumatoid arthritis
- Lupus
- Ankylosing spondylitis
- Sjogren's Syndrome
- Infections
- Flu-like symptoms
- Reiter's Syndrome
- Rheumatic fever
- Rubella
- Meningitis
- Gonorrhea
- HIV/AIDS
- Depression
Past surgical history:
- Joint replacements
- Arthroscopic surgery
- Tendon/fracture repairs
Family History (FmHx)
Specifically ask about:
- Autoimmune: psoriasis, RA, IBD, lupus
- Gout
- Osteoporosis
- Cancer
- Rheumatic Disorders
- Osteoarthritis
- Rheumatoid arthritis
- Lupus
- Ankylosing spondylitis
- Sjogren's Syndrome
Social History (SocHx)
Specifically ask about:
- Occupation
- Repetitive movements
- Heavy lifting
- Posture/ergonomics
- Hobbies
- Repetitive movements
- Heavy lifting
- Posture/ergonomics
- Sports/extracurricular activities
- Exercise
- Repetitive movements
- Heavy lifting
- Posture
- Weight bearing activities
- Delayed onset muscle soreness (DOMS)
- Home Life
- Difficulty with activities of daily living
- Fall risk
- Diet
- Calcium & Vitamin D
- Caffeine intake
- Sexual activity
- STI's (esp. Gonorrhea)
- HIV/AIDS
Substance Abuse History
Specifically ask about:
Medications
Gather complete list, but specifically ask about:
- Pain-relief (NSAIDs, acetaminophen, muscle relaxants)
- Corticosteroids (avascular necrosis)
- Cortisone injections
- Fluoroquinolones (tendon rupture)
- Statins (rhabdomyolysis)
- Bisphosphonates
- Vitamin D and calcium supplementation
- Immunosuppresants
- Tetanus immunization is up to date
Allergies
Note allergies and ensure they concord with those listed in the EMR
Review of Systems
Conduct a review of systems, keeping other etiologies from your differential in mind.
References
- Baxter S, ed., McScheffrey G, ed. Toronto Notes: Comprehensive Medical Reference & Review for MCCQE 1 & USMLE 2. 26th ed. Toronto: Toronto Notes for Medical Students Inc; 2010.
- Bickley L. Bate’s Guide to Physical Examination and History Taking. 10th ed. New York: Lippincott Williams & Wilkins; 2009.
- Filate W, Leung R, Ng D, Sinyor M, eds. Essentials of Clinical Examination Handbook. 5th ed. Toronto, ON. University of Toronto, 2005.
- Hurley K. OSCE and Clinical Skills Handbook. Halifax: Elsevier Canada; 2005.
- Le T, Bhushan V, First Aid for the USLME Step 1 2013: A Student-to-Student Guide. New York: McGraw-Hill. 2013.
- Magee DJ. Orthopedic Physical Assessment 5th ed. Canada: Elsevier: 2008.
- Pawa J, Lesniak, D., & Lott, A. Approach to the OSCE: The Edmonton Manual of Common Clinical Scenarios. Edmonton Manual; 2011.