OnExam

Identifying Information

Gather the patient's general identifying data.

Chief Complaint

Elicit the patient's chief complaint.

History of Presenting Illness (HPI)

Characterize each of the patient's principal symptoms using the OPQRST/OLD CARTS approach

  • Method of Injury
    • Direction of force
    • Joint position
  • Articular Pain
    • Monoarticular
    • Polyarticular
      • Pattern of involvement
        • Migrating vs. spreading
        • Symmetrical vs. asymmetrical
    • SEADSS
      • S-Symmetry
      • E-Erythema
      • A-Atrophy
      • D-Deformity
      • S-Swelling
      • S-Skin Changes
    • Pain
      • Positioning
      • Movement vs. rest
      • Time of day
        • Morning stiffness vs. end of day fatigue
      • Quality (see OPQRST/OLD CARTS approach)
    • Accompanying Symptoms
      • Weakness
      • Paresthesia/numbness/hyperalgesia
      • Joint instability
      • Joint locking
      • Joint clicking, grinding, popping
      • Loss of function
      • Movement limitations
  • Non-Articular Pain
    • Method of injury
      • Direction of injury
      • Type of injury (direct impact, concussive force, stabbing, crushing)
    • SEADSS
      • S-Symmetry
      • E-Erythema
      • A-Atrophy
      • D-Deformity
      • S-Swelling
      • S-Skin Changes
    • Pain
      • Positioning
      • Movement vs. rest
      • Time of day
        • Morning stiffness vs. end of day fatigue
      • Quality (see OPQRST/OLD CARTS approach)
        • Muscle: dull, aching, poorly localized, radiates
        • Bone: deep, well-localized
        • Nerve: burning, sharp, dermatomal distribution
        • Vascular: diffuse, aching, poorly localized, radiates
    • Accompanying Symptoms
      • Weakness
      • Paresthesia/numbness/hyperalgesia
      • Loss of function
      • Movement limitations
  • Axial Pain (Back/Neck)
    • Method of injury
      • Direction of injury
      • Type of injury (Impact, axial force, piercing, crushing)
    • Midline vs. Off Midline
    • Chronic vs. Acute
    • Weakness with fatigue
    • Paresthesia/numbness/hyperalgesia
    • Saddle Anesthesia
      • Bowel incontinence
      • Urinary retention
    • Gait disturbance
      • Trendelenburg gait
      • Gluteus maximus lurch
      • Foot drop
    • Loss of function
    • Movement limitations
    • Headache
    • SEADSS
      • S-Symmetry
      • E-Erythema
      • A-Atrophy
      • D-Deformity
      • S-Swelling
      • S-Skin Changes
    • Pain
      • Positioning
      • Movement vs. rest
      • Time of day
        • Morning stiffness vs. end of day fatigue
      • Qualtiy (see OPQRST/OLD CARTS approach)

Past Medical History (PMHx)

Past medical history:

  • Previous trauma, injury, or treatment
  • Psoriasis
  • Gout
  • Cancer
  • Menopause
  • Osteoporosis
  • Rheumatic disorders
    • Osteoarthritis
    • Rheumatoid arthritis
    • Lupus
    • Ankylosing spondylitis
    • Sjogren's Syndrome
  • Infections
    • Flu-like symptoms
    • Reiter's Syndrome
    • Rheumatic fever
    • Rubella
    • Meningitis
    • Gonorrhea
    • HIV/AIDS
  • Depression

Past surgical history:

  • Joint replacements
  • Arthroscopic surgery
  • Tendon/fracture repairs

Family History (FmHx)

Specifically ask about:

  • Autoimmune: psoriasis, RA, IBD, lupus
  • Gout
  • Osteoporosis
  • Cancer
  • Rheumatic Disorders
    • Osteoarthritis
    • Rheumatoid arthritis
    • Lupus
    • Ankylosing spondylitis
    • Sjogren's Syndrome

Social History (SocHx)

Specifically ask about:

  • Occupation
    • Repetitive movements
    • Heavy lifting
    • Posture/ergonomics
  • Hobbies
    • Repetitive movements
    • Heavy lifting
    • Posture/ergonomics
    • Sports/extracurricular activities
  • Exercise
    • Repetitive movements
    • Heavy lifting
    • Posture
    • Weight bearing activities
    • Delayed onset muscle soreness (DOMS)
  • Home Life
    • Difficulty with activities of daily living
    • Fall risk
  • Diet
    • Calcium & Vitamin D
    • Caffeine intake
  • Sexual activity
    • STI's (esp. Gonorrhea)
    • HIV/AIDS

Substance Abuse History

Specifically ask about:

Medications

Gather complete list, but specifically ask about:

  • Pain-relief (NSAIDs, acetaminophen, muscle relaxants)
  • Corticosteroids (avascular necrosis)
  • Cortisone injections
  • Fluoroquinolones (tendon rupture)
  • Statins (rhabdomyolysis)
  • Bisphosphonates
  • Vitamin D and calcium supplementation
  • Immunosuppresants
  • Tetanus immunization is up to date

Allergies

Note allergies and ensure they concord with those listed in the EMR

Immunizations

Note immunization history as described in the immunization history section.

Review of Systems

Conduct a review of systems, keeping other etiologies from your differential in mind.

References

  1. Baxter S, ed., McScheffrey G, ed. Toronto Notes: Comprehensive Medical Reference & Review for MCCQE 1 & USMLE 2. 26th ed. Toronto: Toronto Notes for Medical Students Inc; 2010.
  2. Bickley L. Bate’s Guide to Physical Examination and History Taking. 10th ed. New York: Lippincott Williams & Wilkins; 2009.
  3. Filate W, Leung R, Ng D, Sinyor M, eds. Essentials of Clinical Examination Handbook. 5th ed. Toronto, ON. University of Toronto, 2005.
  4. Hurley K. OSCE and Clinical Skills Handbook. Halifax: Elsevier Canada; 2005.
  5. Le T, Bhushan V, First Aid for the USLME Step 1 2013: A Student-to-Student Guide. New York: McGraw-Hill. 2013.
  6. Magee DJ. Orthopedic Physical Assessment 5th ed. Canada: Elsevier: 2008.
  7. Pawa J, Lesniak, D., & Lott, A. Approach to the OSCE: The Edmonton Manual of Common Clinical Scenarios. Edmonton Manual; 2011.