If you can take a good history, you're most of the way to a diagnosis before you ever touch the patient.

OLDCARTS is the mnemonic I still use. Onset, Location, Duration, Character, Aggravating factors, Relieving factors, Timing, Severity - plus associated symptoms. It sounds basic, but the difference between a vague complaint and a useful one is just whether you asked all of it.

This is a skill you can start building now, before PA school. If you're a scribe, an MA, a tech, anything where you're around patients, listen for these pieces in the interviews happening around you. And if you're shadowing, pay attention to how the provider steers a patient who's giving you a story instead of an answer.

What I cover:

• What each letter in OLDCARTS stands for
• How to ask about character and severity without leading the patient
• Pinning down onset and timing when the patient isn't sure
• Associated symptoms and why they change your differential
• Practicing this before PA school
• Why a good history saves you on exams and in clinic

Resources:

Free application timeline: https://www.thepaplatform.com/services/free-application-timeline

Free resume download: https://www.thepaplatform.com/services/free-resume-download

PA Program Map: https://www.thepaplatform.com/pa-platform-map

Pre-PA counseling: https://www.thepaplatform.com/services/pre-pa-counseling

Welcome to episode 60.

Today we're talking about how to make sure you get a really good patient history.

Welcome to the Pre PA Club podcast.

If you want to learn how to become a physician assistant, you're in the right place.

I'm your host, Savannah Perry.

Let's get to it.

Alright guys, thanks for tuning in to episode 60.

I'm Savannah, I am your host.

I am the creator of the paplatform.com youm can find me on Instagram, the PA platform and the host of this podcast, the Pre PA Club.

We've been going strong for over a year now, which is really exciting.

I've gotten to do a lot of awesome interviews, meet some really cool PA students and PAs and it's really just been a lot of fun.

So I hope you've enjoyed it too.

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And thank you so much for continuing to listen.

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Make sure you follow along on Instagram @the PA platform and feel free to email me or DM me if you have any questions or thoughts.

So for today's episode I wanted to do something a little different and you can let me know if you hate this.

You can let me know if you love this.

But I was just kind of thinking about what would be helpful.

I know I love doing the interviews and we've done tons of them and there are a lot more coming.

But I also just want to be able to give you guys information that I think would be useful.

Now, I think this particular subject will be useful not only to pre PA students who work in healthcare setting, if you are, let's say a medical assistant or a scribe or a cna, but also to PA students.

Because this is actually something that I learned in PA school that I think is really, really helpful.

So in my field in dermatology, my medical assistant Taylor, who I had on episode a while back, let me see if I can figure out which one that was.

Gosh, it was a long time ago that Taylor joined us, but she is awesome.

Oh gosh, I can't find it.

Anyway, I'll link to that in the description so you can listen to that.

Because she talks about her time as a medical assistant.

But anyway, she does a lot of the questioning of my patients.

So when we talk about the different parts of a note, you have basically a SOAP note.

So we can talk about that at a different time.

But subjective objective assessment and plan is what SOAP note stands for.

Now when you first meet that patient, you've got to ask them a few different things.

So the first things you ask them, number one, is for their chief Complaint.

What brings them in today?

Why are they here?

And so this is important because you want to know what the visit should focus on.

I'm in dermatology, so sometimes that looks like a rash or a spot or a lesion changing or bleeding.

We want to know what brings them in.

That's not to say that they may only have one thing bringing them in, but it helps to kind of get the visit going.

So then you need to know more about that problem, and that's where you're getting those details for your HPI or history of present illness.

So when I was in school, we learned something called old carts, and that's what I'm going to teach you today.

I'm going to teach you what types of questions you need to be asking to get a thorough history.

If you are working in the medical field, let's say as a pre PA student trying to go to PA school, you want to do a good job.

You want to impress the people that you're working with so they give you a great recommendation and feel confident that you'll be able to succeed as a PA student and as a pa.

So that's where this comes in.

I mean, you want to really put in some effort to make sure that you're doing a good job.

And then you get into the review of systems, which we're not going to talk about in detail today.

But like I said, if you feel like this type of information is helpful or there's some other practical thing that you would like to know more about, please let me know and I will do my best to do an episode on it.

All right, so hpi, history of present illness.

You've got that chief complaint, that thing they're in for.

And we'll do an example of this at the end.

After that is when you ask more questions.

So, like I said, we learned this as old carts, and that is just mnemonic to help you remember the things you need to ask.

That does not mean that you necessarily have to ask these questions in order or that you have to ask all of these questions, but there are some that are pretty important to know almost every single time.

I'm going to list those out and then we're going to talk about each one in a little bit more detail.

There are a few that have a little bit extra to them or like kind of two things, so we'll add those two.

So, O is the onset.

L is for location.

D is for duration, disability.

C is for character.

A is for aggravating factors, associated symptoms.

There's another A. I tricked you.

There's a lot of as, another A for attribution, an R for relieving, in parentheses, alleviating factors, and T for timing, treatments tried, and S for severity.

So let's kind of break these down a little bit.

And then, like I said, we'll go back through and do an example, so.

Or location.

I skipped the O.

Let's start with O.

So for O onset, this is when the problem started, or each symptom, each problem.

If somebody has a lot of things going on, but this is something I ask a lot.

So if somebody has a lesion or a rash, I want to know how long it's been there.

So I don't necessarily want to know, oh, it started on a Tuesday.

I want to know.

It started two weeks ago, or it started three days ago.

There are a lot of phrases out there that patients like to use, which can make this question a little frustrating.

And it's almost like pulling teeth, trying to get when it started.

So they'll say a while, a little bit.

It's been there for a minute.

That doesn't help me.

So I try to ask very specifically, when they give me that type of answer, I'll say, okay, is that like a month, a year, six months?

As long as you can remember since you were a child?

Give me a little more information.

So that's the first thing.

Just when did this start?

How long has it been going on?

Is this a new problem that has come up over a week, or have you had this same problem for 10 years, but today is the day we're going to take care of it?

Those are the things that I need to know.

So O is for onset.

Moving on to L for location.

You want to know where this problem is taking place.

And some things may not have a location.

If somebody has.

If they're just feeling, oh, gosh, I guess most everything I think of right now would have a location.

But it may be hard to pinpoint.

Let's say someone's having anxiety.

They may not have necessarily a location.

They may be able to tell you their heart's racing, their chest feels tight, but they may not really.

It may just kind of be a generalized feeling.

But if someone's having pain, if they're having itching, my patients have itching, and they like to tell me it's all over.

But try to locate it, see if they can point to it with a finger.

See if you can figure out where it started, is the location that you're seeing it at now, the Same as the one where it started.

If they had a rash that started on their abdomen, is it still there?

Or is it on their back now?

And if it is something that includes pain, does that pain radiate?

Are they having chest pain?

Does it radiate to their shoulder?

Does it go anywhere else?

You just want to think about asking these types of questions to try to get that information out.

Moving on to D, which is duration.

For the first one, how long has this been going on?

And if it's something that's kind of intermittent, that comes and goes, what's the longest period of time that has lasted?

What's the shortest?

When is the last time it happened?

Does it ever go away completely?

Does it come and go constantly?

Just kind of figuring out what the timing is of this problem, whatever it may be.

And then we move on to disability, which is the other part of the Ds.

And have they had to cut back on anything?

Is it so severe that they are not able to do their work or activities?

They enjoy an example of this.

So in dermatology we see a lot of hand dermatitis and sometimes people's hands are so raw and cracked that they can't even do their hobbies.

I mean, they may love doing woodworking.

Or I've had someone who part of their job was typing and being at a computer all day and their hands were so cracked that it just made it really difficult to, to actually do their job.

So those are things to also think about.

And that will help you realize how much distress the patient may be in and how much this is really affecting their quality of life.

So we've done old moving on to carts with the C character, describing what this symptom or problem feels like, describing the quality of it.

So if it's a pain, is it sharp, dull, throbbing, stabbing?

If it's itching, does it have a burn to it?

Is it a painful itch?

Is it deep?

Is it all the time?

Not all the time, but you want to try to kind of get that description.

And when you're asking questions, it's best to start with an open ended question.

So just describe the pain, Give me something.

If that patient struggles with that and really can't do it, then move on and try to give them some choices.

So then you say, well, does it feel like someone's stab stabbing you or is it a stinging pain?

Like, tell me a little bit more about what you're feeling and give them some thoughts to try to direct their answer a little bit.

And again, some symptoms May not necessarily be able to describe really well, but do your best.

And if someone's coming in, let's say for like a blood pressure follow up and they're doing great, you're not necessarily going to be able to ask them questions like this, That's a little bit different.

But just use your judgment when asking appropriate questions.

Okay.

Moving on to a lot of as.

So the first one, aggravating associated factors.

What things go along with this problem?

Is there anything that the patient knows that they do to make it worse?

If you use bath and Body Works, does your rash get worse?

Most likely, yes.

If you take really hot baths, do you itch more?

Probably, yes.

What were you first doing when this happened?

Were you working in your yard and then the rash appeared?

Is there anything that you do that makes it worse?

If you eat a hamburger, does that make your stomach hurt more and make your pain worse?

That is something else to think about.

And then are there any other symptoms that go with it?

So if you can say, yeah, you know, my stomach hurts when I eat a hamburger, but then I also feel nauseous, like it's pain, but I'm also having nausea, what else goes along with this?

And so one thing I see is sometimes people have itching.

They'll be like, there's a spot on my back that is itching so bad.

I look at their back.

There is not a thing there.

Not a mole, not a keratosis.

There's nothing there.

Because sometimes it's a nerve itch, what we call a no talgia.

And that type of itching can feel really deep.

It can be really, really annoying.

And it's really important that you kind of look when you look at that patient, but then you ask questions about that itching and what makes it occur and if there's anything that precipitates it.

And then any other symptoms.

The next A is attributions.

So this one can get a little foggy, but we want to know what that patient thinks is the cause.

Why does the patient think it's happening?

Now?

Sometimes medicines get a bad rap and they get blamed for things that they don't really cause.

I had a patient call me and tell me that a cream that they were using was causing their diarrhea, was causing them to have diarrhea.

Upon further inspection, that patient was already on a bunch of medicines for diarrhea.

And so they were just having an exacerbation.

But because they started this new cream that does not cause diarrhea, they felt like it was the cream.

So it's very easy to kind of attribute things.

And if you go on Dr. Google, you'll find that pretty much all of your medicines and anything can cause this.

So.

Yeah.

But anyway, as far as attributions, I mean, ask about these, but take them with a grain of salt, document them.

Well.

And sometimes it may be the case.

A patient may say, you know, I know that if I had a bowl of ice cream every single night, my breakouts are going to get worse.

And that's fine.

That is probably right.

So, I mean, they may need to stop that.

But there may be attributions that are not necessarily really the cause, but it's still important to ask about them and document them.

Okay, moving on to our r relieving or alleviating factors.

What has this patient done to try to solve the problem and has it worked?

Has it helped?

Have they ever had this before and never done anything else before?

Are they using any creams, taking any medicines?

Have they tried any home remedies?

You really just want to know what's already been done because it's better than going in with a blank slate and having to try to figure out something or you offer something and they go, oh, I've already done that, I've already done that, I've already done that.

So it's better to just go ahead and ask and figure out what they've tried, what's worked, what hasn't, so that you can offer better suggestions or your provider can.

Moving on to t timing.

So this one is a little bit difficult to explain and understand, but this is kind of the context of the problem.

What kind of setting the scene?

I guess so what was happening when this started?

What was going on?

So something for, like, anxiety.

What was going on?

Were you had.

You just had a car wreck and you just broke up with your boyfriend?

Like, what was going on during that time period for acne?

You know, what has been going on?

Have you been extra stressed out?

Did you just switch birth control methods?

Did you stop using all your medicines or start using all new products?

Kind of give me some of that context about what has been happening to maybe give me some background so I can start thinking about what could have caused the problem.

Some questions to think about.

What were you doing when.

So what were you doing when your chest started hurting?

Where were you when your ankle popped?

What was going on around you at the time?

Those types of questions are going to give you that context to kind of figure out the timing.

We are at our S which is the Last part of old cards, severity.

So this one is kind of, this is where you would use a pain scale and try to get them to rank it.

I do not use this one very much in what I do.

Maybe for psoriasis, if they're having some joint pain, I would ask, you know, on a scale of 0 to 10 and 10 is the worst pain you've ever experienced, where are you at?

I would squeeze their joints and kind of watch for any movements or facial expressions to give me some idea.

And then again, you can ask about disability, but with this one, you just want to know what it has done to them.

So think about, like, if somebody thinks someone's having a heart attack, you want to know how bad that pain is.

But again, like some of this, you may not get a severity of pain.

It may also just be how much does this affect your life?

So like with acne, if I'm talking to a teenager, like, you know, how bad is this affecting you?

How bad is this affecting your confidence and how you feel about yourself?

And that will help me figure out kind of how much work they're going to put into getting their treatment better.

Okay.

So that's just kind of the basics of taking an HPI and things you want to ask about a problem.

So that's old carts.

Let's say here we'll use an example from dermatology, because that is what I do.

And so let's say somebody comes in and their chief complaint is, I have a lesion on my arm.

They probably wouldn't say, lesion, I have a bump on my arm.

So what I'm going to want asked and what I'm probably going to ask and what Taylor, my medical assistant, is going to ask is when did this start?

How long have you noticed that bump?

Okay, six months.

All right.

And we already know the location.

Can you show me where it is?

So they point to like their forearm.

So I'm gonna kind of look at that and know that that's where it is.

And I know that's a sun exposed area duration.

So I'm gonna ask them, you know, has it been there the whole time?

Does it come and go?

And they may tell me that it kind of will go away or they'll peel it off and then it comes right back.

And then I may ask them if it, if it's painful or if it causes them.

So we're moving on to character.

What does it feel like?

Is it painful?

Is it tender?

Is it itchy?

Is it growing?

Just to get some input, there has it caused you any problems?

And usually it hasn't.

It's just been sitting there.

And then aggravating factors or associated symptoms.

Does it bleed?

Is it.

Does it hurt if you hit it?

Is there anything that has made it grow, has seemed to make it better or get smaller or go away?

And then attribution.

Did you do anything that you think caused this?

And sometimes people, I mean, I've had people say, oh, I got hit in the back with a stick.

And then I look and it's a melanoma and it's just a sore that hasn't healed forever and ever.

Or some skin cancers can actually be caused by trauma.

And I've seen that on the legs, like, oh, I got poked by a thorn on a rose bush.

And then they get a skin cancer.

Other things, relieving factors, alleviating factors.

Have you done anything to try to make it go away?

Have you put any cream on it?

Have you?

I know you said you picked it off.

How quickly does it come back?

And then also kind of the timing treatments, I kind of covered that a little bit.

But as far as timing, when did you first notice this?

What made you notice it?

And they may say, you know, I rubbed my arm against a door and it kind of hurt.

And that made me realize something was there.

And then severity.

So how painful is this?

How much is it causing you a problem?

And I would ask all those questions and all of this stuff makes it into the notes.

So documentation is so, so, so important for a lot of reasons.

I mean, definitely from like a law standpoint, but also just for yourself, when you go back and look at a record or if your supervising physician looks at a record, it' important that everything is in there.

But yeah, so that is old carts.

And again, I hope this was helpful.

If it wasn't, let me know and let me know what would be.

But I just kind of thought this would be a nice mix up.

And next week we'll be back with an interview and I will be at a derm conference, which I am so, so excited about.

Make sure you're following along on Instagram so you can see all my stories about my derm conference next week.

Thank you for tuning in, guys.

See you next time.