The third major question we want answered when someone is telling us that they need help - after ‘who are you?’ and ‘what’s wrong?’ - is ... ‘what happened’?  That’s what we medical-types call the ‘incident history’, often abbreviated in medical charts as ‘IHx’

The incident history is the ‘story’ or what went wrong.  A lot of the art in medicine revolves around learning how to actually find out what happened accurately, and in a relatively short amount of time.  This takes a lot of practice, and a lot of knowledge.  It’s a constantly evolving skill that you will never stop improving.

I intend to (one day) add a section to the site that describes the 50 or so major chief complaints and presenting conditions that we see over and over as medics, and to include brilliantly written and deeply insightful information on how to interview these patients, but that day hasn’t happened yet.  Sorry.

In the meantime, here is my take on the common ‘OPQRST’ mnemonic taught in EMT-B classes around the world to guide our inquiries into ‘what happened’.

N - I start with ‘N’, which is a bit different from what most textbooks teach.  For me ‘N’ stands for ‘Normal’, and it reminds me to ask ‘when did you last feel normal, or fine’?  Sometimes people tell you that they have bad chest pain that started ten minutes ago, but when you ask them when they last felt totally normal they’ll say ‘about a week ago, before I pulled my arm muscle moving heavy boxes’.  At that point you worry less about anginal chest pain, and start to think more about musculoskeletal (MSK) pain.

O - stands for onset.  How and when did this start?  Specifically, ask these questions: What time did it start?  Has it been intermittent or constant since then? (If intermittent, how so?) What were you doing at the time?  Did it start suddenly or gradually? And, if gradually, describe the progression.

P - stands for Provocative (what makes it come on, or makes it worse) and Palliative (what makes it better)?  If they’re dizzy, do they get more dizzy when they stand up (provocative) and less dizzy when they lie down (palliative)?  What can they do, if anything, to change the chief complaint?

Q - stands for ‘Quality’, and it reminds you to ask the patient what the chief complaint feels like - what is it’s quality.  For example, for a chief complaint of chest pain I’ll first ask the open-ended question ‘What does it feel like’.  If I can’t get a clear answer, I’ll eventually narrow it down the the closed-ended question, “Which description fits best: crushing, burning, tearing or stabbing”?

R - Sometimes patients have pain that ‘radiates’ somewhere else in their body.  The classic example being anginal chest pain that radiates to the left arm or jaw.  If it makes sense to ask, giving the chief complaint, then ask if there is any radiation.  Sometimes, (like with shortness of breath) it doesn’t make sense to ask about ‘radiation’ of their shortness of breath, so don’t ask.  But if you can ask about it, make sure you do.

S - stands for ‘severity’, and we often ask our patients to “rate their pain on a scale of one to ten with one being no pain and ten being the worst pain you’ve ever had in your life’ (how many times in my life have I repeated that phrase!).  Don’t switch this around.  Don’t, for example, say ‘with ten being no pain and one being the worst pain you’ve ever had in your life’ because that will mess up all the other medical professionals who read your chart.  1/10 means very little pain, and 10/10 means a lot of pain.  Don’t reverse it. 

T - is often taught as ‘time’, as in ‘time of onset’, but we already cover that in ‘onset’, so I have no idea why people teach that.  Instead, T means two different things for me.  The first is ‘typical’, for example ‘Is this pain typical for you? Have you ever had this - like this - before?’  The second thing I ask about is ‘Trauma’.  Was there any trauma that might have lead to this complaint?  For example: has the patient with altered mental status been hit in the head, has the person with chest pain been hit in the chest, or pulled a muscle, or have they been coughing harshly for several days?  All of those situations could lead to a traumatic cause of pain that you might not discover if you don’t ask specifically about it.

U - optionally, if you wanted to, you could use ‘U’ to stand for ‘Undigested food’, and that would be a reminder to ask the person when the last time they ate was.  This isn’t anywhere near as important a question as American EMT-B textbooks all seem to think it is, (if you need to intubate, you’ll just intubate) but often students will be tested on whether or not they asked this question.  So, this is a good place to plug it in if you want to.

Overview

I         Identify the Patient

C        Chief Complaint

I         Incident History

H        Past Medical HIstory

A        Allergies

D        Drugs

VS       Vital Signs

As.       Assessed   and

Tx       Treated