For all symptoms, it is important to fully understand the essential characteristics. Always pursue the following features for every symptom. The Bates textbook calls them the features of every symptom.
**When describing the symptoms in a problem presentation, use semantic qualifiers whenever possible.
OPQRST-A
- Onset – Onset means the beginning of something. Describe the onset in detail with the 5Ws and 1H: When did the pain start? Where were you? What you were doing when the pain started? How did it start or come on (sudden or gradual)? Why does the pt think the pain came on? Also, ask freq and duration of each episode. Have the pt paint a picture of the environment and setting. e.g., relation to meals, exertion, etc.
- Provokes / Palliates – What makes it better? What makes it worse?
- Quality – This is the character of the pain. What is the pain like? An ache? Stabbing?
- Region and Radiation – Point with one finger to where it hurts the most. Where does your pain go from there?
- Severity – On a scale of 0 to 10, where zero is no pain and 10 is the worst pain ever, how bad is the pain? What quantity of sputum do you produce (how many cups, teaspoons, etc.)
- Time course – Does the pain follow any pattern? Continuous or episodic? “How long the condition has been going on and how it has changed since onset (better, worse, different symptoms), whether it has ever happened before, whether and how it may have changed since onset, and when the pain stopped if it is no longer currently being felt.”
- Associated symptoms – Any other signs or symptoms associated with the pain? E.g. For chest pain: diaphoresis, nausea, dyspnea, radiation to jaw and arms?
Some semantic qualifiers have been underlined below.
Onset
Onset means the beginning of something. Describe the onset in detail with the 5Ws and 1H.
When did the pain start? Where were you? What you were doing when the pain started? How did it start or come on (sudden or gradual)? Abrupt or progressive, acute or chronic? Why does the pt think the pain came on? Also, ask frequency and duration of each episode. Have the pt paint a picture of the environment or setting in which it occurred. e.g., relation to meals, exertion, etc.
What was the patient doing physically; emotionally, psychologically/mentally; socially; and spiritually? Consider physical activity, emotional stress/anxiety, mental stress/worry, social stress, spiritual stress, environmental factors, or anything else that may have contributed to the disease. E.g. Travel, drinking from a well, working on a farm, living in an old house, etc. Was he active, inactive, stressed, calm? Acrostic for setting: MESS – Material or physical word (body and the surrounding world), Emotional/psychological/mental, social, & spiritual. These are the four fundamental relationships.
Palliating & Precipitating factors
Does anything make it better or worse? Does any movement, pressure, or other external factors make the problem worse or better? Does rest relieve the symptoms? Is it post-prandial, exertional, pleuritic, positional?
Quality
For pain, what is the pain like? Is it sharp, dull, burning, crushing, pulsating/throbbing, cramping, tearing, pressure-like? Is it constant or does it come and go?
Region and Radiation
What region or location is this pain found? Does it radiate or spread to any other area? You want to also note if it is unilateral or bilateral, proximal or distal, diffuse or localized, radiating vs. non-radiating.
Severity or Quantity
On a scale of 1 to 10, where does it fall? Painful or painless? Can you estimate the amount of phlegm for me? Teaspoon? Tablespoon? Cupful?
Time course
Does the pain follow any pattern? When it starts, how long does it last? How often does it happen? (frequency) Is it continuous or episodic? How has it changed since onset (better, worse, different symptoms)? Has it ever happened before? You want to know whether and how it may have changed since onset, and when the pain stopped if it is no longer currently being felt.
Associated Manifestations
Have you noticed anything else that accompanies it? E.g. For chest pain: diaphoresis, nausea, dyspnea, radiation to jaw and arms?