Medical History and Physical Exam Key Mnemonics and Techniques

Chief Complaint (CC)

Main reason or symptom bringing a patient in for care

OPQRST

Mnemonic for history taking during pain assessment

Onset (O)

What patient was doing when symptoms started; sudden vs gradual

Provocation / Palliation (P)

What makes symptoms better or worse

Quality (Q)

Description of how pain feels (sharp, dull, throbbing, etc.)

Region / Radiation (R)

Where pain is located and if it moves elsewhere

Severity (S)

Intensity of symptom on a 1 to 10 scale

Time (T)

When signs/symptoms first occurred and duration

HITS

Past history mnemonic: Hospitalizations, Illnesses, Traumas, Surgeries

Review of Systems (ROS)

Head-to-toe systematic interview inquiring about symptoms in each organ system

Inspect

Visual observation of patient's body (Uses penlight, otoscope, ophthalmoscope)

Palpate

Feeling body parts with hands/fingers to assess texture, size, tenderness (Uses examination gloves)

Auscultate

Listening to internal body sounds (Uses stethoscope)

Percuss

Tapping body surfaces to produce sound based on tissue density (Uses reflex hammer/fingers)

Special Studies

Diagnostic testing (Lab work, X-rays, CT scan, MRI, EKG)