what should I ask?

[cointosser13]

I recently found out that asking the OPQRST questions are rarely good enough to ask out in the field. So what kind of things do you ask? I've seen medics ask various questions, and they all make sense, but if I were to ask, I wouldn't know where to start. I know asking anything will narrow your search for what's wrong, but I don't want to annoy my patient with a million questions before I feel comfortable with my assessment. If you could just give me some generic questions that are good to ask that would be great. And yes...I know, "what's going on, or what's wrong today" is good to start with. But what else?

 

[Achilles]

How did this happen?
How long ago did this happen?

Guess what, you'll ask a question in the rig or the Pt's residence. And the minute to nurse asks the question, it will change.
For example,
EMT: "Are you allergic to anything" (medications, latex, food, etc)
Pt: "oh no I'm not allergic to anything."
Nurse/ Dr/ tech/ Mickey Mouse. : Are you allergic to anything:
Cue pt listing long list of allergies.



I'll ask this question more than once, and on many Pts I'll get a different answer each time. I wish I could change that, but I think first I would have to change the way people view Public health.

Don't ask such vague questions,
Eg. "How are you doing?" Well they called 911, how do you think they are doing?

 

[wanderingmedic]

I recently found out that asking the OPQRST questions are rarely good enough to ask out in the field.

Not quite. OPQRST is still a helpful pneumonic.

I think most people gather the information of SAMPLE and OPQRST - but just with their own finesse/style. No, I do not go through letter by letter anymore, but I still gather all of the info I need to treat the pt correctly. I have found it is always worth erring on the side of caution and asking too many questions. Pt's expect you to ask questions anyways. Asking intelligent questions helps to build confidence in the patient provider relationship, and shows that you have a clue because you are asking questions that are helping you to find out what is wrong.

 

[chaz90]

Generic questions are rarely the key. Specific assessments and exams come with increasing education and experience. The more you learn, the more you'll discover what questions will give you useful information. Last oral intake may be relevant if you're thinking allergic reaction, heartburn, or food poisoning, but people will laugh at you if you pull that one out on the stabbing victim. Your questions should ideally be guided by answers that pt. has already given you.

I.E
SAMPLE and OPQRST may lead you to find out Nana fell and has wrist pain. Ok, that's all well and good, but let's talk more about that fall. Follow up with asking what made the pt. fall. She might say she was "dizzy" before the fall, so ask what she means by that. Was her vision darkening? Did the room spin? Did she simply lose her balance? These answers are important and can really aid in coming up with an educated list of differentials.

At some point during the questioning, you need to find out if these symptoms have ever happened to the pt. before. This doesn't rule out other causes, but it may lead you down a likely road.

 

[STXmedic]

That's an extremely broad question. Every patient is going to have different questions I'll ask. There will be differences from headaches, to abdominal pain, to chest pain. There will even be different questions asked to different patients with the same complaints. It just comes with practice.

Most of your questions will be directed by information the patient gives to you. Each new question is to probe deeper. Once you start developing differentials, start asking questions to either confirm or reject them.

 

[JPINFV]

A lot of it is about knowing what diseases are out there, how they present, and how to differ between them. For the history of present illness (i.e. not social history (alcohol, drugs, tobacco, and when pertinent, work, travel, sex, etc), medical hx, surgical hx, allergies, medications, family history etc), OPQRST is pretty good if you nail them down.

O: What were you doing when it started?
P: What makes it better/worse? Have you taken anything for it? Did that help? Does ____ make it worse?
Q: Can you describe it? Is it sharp/dull/achy/etc?
R(egion): Where does it hurt? Where did it hurt when it started? (e.g. appendicitis often starts around the umbilicus and then migrates down to RLQ) Point with two fingers.
R(adiation): Does it move anyplace? Has it moved anyplace at all?
R(eoccurance): Have you had this occur? How often do you get it? How does this time compare to prior incidences?
S: On a scale of 0-10 with zero being no (issues/pain/difficulty) and 10 being the worst you can imagine, how does it rate right now? When this incident started?
T: How long has this occurrence been going on for?

Remember to go from broad, open ended questions ("How can we help you today?" vs "So the pager told me you had chest pain, how's your chest pain?"), and you'll start to learn what questions are important to ask.

 

[Akulahawk]

In addition to the above stuff, I will ask what pills or herbals they take... and where those pills are. We all know that people don't have medical problems because they take pills for that. I'll also ask about any discomforts anywhere. Why? People might feel something as a discomfort that isn't necessarily all that painful. I'll ask about the last time they peed, pooped, or consumed anything (liquid or food). I'll also ask if they've ever had this issue (whatever it is) before, was it diagnosed, and what did "they" say it was. When I take a history, I ask it like this: "Is there any medical problems that a Doctor needs to know about, because if you become unconscious, I need to be able to tell the team."

People often change or add to their story based on what they think you need to know to do your job or to get what they want at the time. I've seen the patient change their story, medical history, meds, allergies... depending upon who was asking about that stuff, more times that I can remember.

ETA: ARGH!!! JP (and a few others) posted before I could...

 

[Ecgg]

I recently found out that asking the OPQRST questions are rarely good enough to ask out in the field. So what kind of things do you ask? I've seen medics ask various questions, and they all make sense, but if I were to ask, I wouldn't know where to start. I know asking anything will narrow your search for what's wrong, but I don't want to annoy my patient with a million questions before I feel comfortable with my assessment. If you could just give me some generic questions that are good to ask that would be great. And yes...I know, "what's going on, or what's wrong today" is good to start with. But what else?

Why do you think asking OPQRST question are rarely good enough to ask out in the field?

Let me ask another question if you were to conduct the patient assessment that they educated you on day after day in your class systematically in order (ABC's OPQRSTI SAMPLE, Physical Exam etc), every time on every patient. What sort of vital patient assessment information would you be missing?

 

[Ecgg]

A lot of it is about knowing......

JPINFV are you able to post the template of patient assessment that as a physician you currently use?

 

[JPINFV]

JPINFV are you able to post the template of patient assessment that as a physician you currently use?

The trick is there is no template. A patient with chest pain is going to be worked up differently than one with abdominal pain vs MSK pain vs weakness vs neuro deficit vs a well child check vs psych vs OB/Gyn issues vs...

 

[NomadicMedic]

It should be a conversation, with questions dovetailing from the last answer.

Asking a set series of questions doesn't do much good if you don't connect the answers to your next question.

 

[FLdoc2011]

This is where experience and education make a huge difference

For things like PMH/PSH, social history, meds, ROS, etc... I usually ask those the same way each time. There's really not trick there besides coming up with a pattern/order that you follow each time so that you don't miss something.


The HPI is the tricky part that becomes an art in and of itself. The mnemonics taught are good to start with so you at least cover some basics (onset/location/duration/quality, etc...) but leave a lot to be desired if its not a simple "pain" complaint.

Initially I'm asking more general/open ended questions to get an idea of what the main issue is and to get the patients "narrative".... "Why did you come to the ER tonight". "What happened today?"

From there I'm developing a differential diagnosis in my head which will lead me to ask certain more specific questions.

So if it's chest pain then I have certain specific questions related to that that I ask, if they c/o HA then it's another set of questions which I've developed over time.

So it's a dynamic process. The trick is if something isn't in you differential then how would you be expected to ask a potentially important related question?

During training it was always humbling when I just got done taking a 45min history only to have my experienced attending walk in and quickly ask a specific /relevant question I hadn't thought of that changed our diagnosis/management. Happens to everyone.

 

[Ecgg]

The trick is there is no template. A patient with chest pain is going to be worked up differently than one with abdominal pain vs MSK pain vs weakness vs neuro deficit vs a well child check vs psych vs OB/Gyn issues vs...

Sure, I understand that. I meant your write ups (or notes) do you write each one from scratch or you have a certain template that you use?

 

[Akulahawk]

Just google "History and Physical" and you should find a whole bunch of links to the format/template they use.... however, that template isn't going to do you a whole lot of good without knowing what to write for each section/heading/whatever. In a way, it's very much a blank page.

 

[JPINFV]

Sure, I understand that. I meant your write ups (or notes) do you write each one from scratch or you have a certain template that you use?

For the actual note, it really depends on the service and the facility I'm at. The main county hospital I did most of my rotations at has a 3 page H/P packet that gets filled out (actually 5 pages, but one is for the senior resident, one is for the attending). When it came to peds, OB/Gyn, surgery, and anesthesiology, they all had very specific forms that gave them exactly what those services wanted. They were very good at making med student proof forms.

When I have to write one out by scratch for things like standardized patients, it goes something like this:

Subjective:
C/C
HPI
Allergies (including reaction)/medications/medical hx/surgical hx in what ever order I feel like putting them that time. However, separate headings Med hx is always followed by Sx Hx.
Fam Hx/Soc Hx (again, what ever order I feel like, but different headings)
Review of Systems (basically a catch all for standard questions regardless of chief complaint. Like a box of chocolates, you never know what you'll find).

Objective:
VS (pulse, resp, BP, temp, pain)
General
HHENT... etc. Top to bottom, what ever I feel like I need. Organize how you'd like as some things can go in multiple boxes depending on what the complaint is.
Lab values
Imaging

Assessment
Primary complaint (DDx 1, DDx 2, DDx 3)
Secondary diagnosis (e.g. sepsis if not severe sepsis or shock (I'm in "SIRS" every time I hop on a treadmill :wacko, lab diagnosis like hyper/hypokalemia, anion gap metabolic acidosis etc)
Medical history that has to be managed/watched (e.g. HTN, hypothyroid, etc)

Plan
Often combined with assessment if I'm splitting plan up by assessment. Otherwise just on it's own. Depends on the situation and how often I want to just write "monitor" for the hypokalemias of 3.4_

 

[Akulahawk]

Take out JP's comments and you're left with a bunch of headings... Note that JP's H&P note is just a very expanded SOAP note... I'm going to remove those comments just to give you an idea what I mean.

For the actual note, it really depends on the service and the facility I'm at. The main county hospital I did most of my rotations at has a 3 page H/P packet that gets filled out (actually 5 pages, but one is for the senior resident, one is for the attending). When it came to peds, OB/Gyn, surgery, and anesthesiology, they all had very specific forms that gave them exactly what those services wanted. They were very good at making med student proof forms.

When I have to write one out by scratch for things like standardized patients, it goes something like this:

Subjective:
C/C
HPI
Allergies
medications
medical hx
surgical hx
Fam Hx/Soc Hx
Review of Systems

Objective:
VS (pulse, resp, BP, temp, pain)
General
HHENT... etc.
Lab values
Imaging

Assessment
Primary complaint (DDx 1, DDx 2, DDx 3)
Secondary diagnosis
Medical history that has to be managed/watched

Plan

As JP hinted at, this format is pretty flexible as it allows you to customize your charting to your need.

I still remember how to write those notes but as I've changed careers a couple times, what I write in those notes has changed to reflect what needed to be included. JP's notes will have more info in them, when written as an H&P than mine likely ever will because his needs and the needs of the service he's on will be very different than what my needs are in my situation.

And yes, I very much prefer the SOAP format.

 

[MountainMedic]

I agree with what others have said - it's a dynamic process. MOST IMPORTANT: a good knowledge of pathophysiology guides your history. If you know how the body works, you'll know what you want to ask. Here's an example of questions I'll ask in different settings, by no means all-inclusive:

All patients: Recent changes in diet or Rx, recent illnesses. Onset is seldom fully investigated, and is very helpful in DDx. Rapid/gradual/sputtering.

Abdominal Pain: Which came first, N/V or pain (pain first means more likely surgical), any and all previous abdominal surgery (adhesions are common cause of pain and GI bleeds), r/o GI bleed, previous occurrence. What's their diet like? Half the time they can tell you exactly what's wrong with them based on Hx alone. Do they squirm or stay still? Is pain colicky (crampy) or constant? If female, all OB/GYN Qs as well.

CP: Good example of OPQRST working well. The tough part is what it means (e.g. radiation to L arm means 2x more likely to be cardiac, R arm 3x, both arms 7x). Previous stents, INR if anticoagulated (educated pt will know it). Is pain pleuritic (PE, pericarditis, costochondritis)? Is pain relieved by sitting up (CHF, pericarditis)? Orthopnea? Etc.

Resp: See above. Also, has pt been intubated/CPAPed? Frequency of attacks? ICU admissions? How often do they use inhaler? Does it work? Do they use flow meter at home?

OB/GYN: 12-60 y/o. LMP, G/P/A. Protection, whether sexually active. r/o pregnancy. Missed ectopic pregnancy is responsible for 5% of all medical malpractice suits. This is as far as I go most of the time - number of sexual partners can be left to their PCP, esp. if it's just me in the back. If known pregnancy - prenatal care? How far along? Normal course? Twins? Braxton Hicks? Any complications? Preeclampsia? Gestational HTN or DM? If in labor, clear water upon PROM (r/o meconium)?

Neuro/AMS: Full neuro exam takes priority. Gait, stroke screen, mental status, cranial nerves (there are 12 of them. Test them all). Get a baseline of the pt's normal abilities and mentation. When I was in medic school I called a false stroke alert because I wasn't thorough enough in ascertaining the pt's baseline.

Those are the fields in which the most addtl Qs are warranted, as far as I can remember. It's common sense, for the most part. As you get better at Hx's, just think "What else would a doctor want to know" as you do it. You'll forget to ask very obvious questions for quite some time. Exam, of course, is a whole other subject...