26 | History Taking

differential field diagnosis

a list of possible causes for a patient's condition

chief complaint

pain, discomfort, or dysfunction that caused the request for help

primary problem

principle medical cause of the complaint

OPQRST-ASPN

mnemonic for exploring each complaint

onset

OPQRST-ASPN | O

provocation/palliation

OPQRST-ASPN | P

quality

OPQRST-ASPN | Q

region/radiation

OPQRST-ASPN | R

severity

OPQRST-ASPN | S

time

OPQRST-ASPN | T

associated symptoms

OPQRST-ASPN | AS

pertinent negatives

OPQRST-ASPN | PN

paroxysmal nocturnal dyspnea

sleep-disturbing breathing difficulty caused by fluid accumulation in the lungs

tenderness

pain on palpation

referred pain

pain that is felt in a part of the body away from the source of the disease or problem

left arm

occasionally neck, jaw, back

cardiac problems are usually referred to the …

clavicular region

pain associated with irritation of the diaphragm is generally referred to the …

pertinent negatives

non-present symptoms that help rule out a differential diagnosis

diuretic

a patient taking a … (“water pill”) likely has a history of renal or cardiac problems

SAMPLE

mnemotic for obtaining history for trauma patients

signs and symptoms

SAMPLE | S

allergies

SAMPLE | A

medications

SAMPLE | M

past history

SAMPLE | P

last time eaten

SAMPLE | L

events leading up to the incident

SAMPLE | E

CAGE

mnemonic for alcoholism screening

cut down (“have you ever felt the need to cut down on your drinking?”)

CAGE | C

annoyed (“have you ever felt annoyed by criticism of your drinking?”)

CAGE | A

guilty (“have you ever had guilty feelings about drinking?”)

CAGE | G

eye opener (“have you ever taken a drink first thing in the morning as an eye-opener?”)

CAGE | E

head, eyes, ears, nose, and throat

HEENT exam

tinnitus

ringing in the ears

hemoptysis

coughing up blood

dyspnea

shortness of breath

orthopnea

SOB while lying flat

intermittent claudication

intermittent calf pain while walkingh

hematemesis

vomiting blood

polyuria

excessive urination

nocturia

excessive urination at night

hematuria

blood in the urine

dysmenorrhea

difficulty with menstruation

GPAL

mnemonic for documenting history of pregnancy

Gravida (“how many times pregnant?”)

GPAL | G

Para (“how many viable births?”)

GPAL | P

Abortions (“how many abortions, including miscarriages?”)

GPAL | A

Living (“how many living children?”)

GPAL | L

asthma, bronchitis

respiratory causes for generalized wheezing include…

bronchodilators

asthma and bronchitis are managed with …

CHF

cardiac causes for wheezing include …

CPAP, vasodilators

CHF is managed with …