A chief complaint of pain is one of the most common encountered by practitioners in any specialty. The pain may be acute or chronic. It may be located in the abdomen, chest, head or any other body part. It may be spontaneous in onset or may be due to an injury. It can range from minimal discomfort to a 15 on the pain scale of 1 to 10. The seriousness of the pain may vary from life-threatening to embarrassingly minor. The patient’s description of pain may be pinpointed and exact or agonizingly vague. Regardless of its characteristics, pain is what brings patients to healthcare providers by the millions every year.
The problem with pain from the patient’s perspective is that they often do not know what is wrong and they may not care - they just want the pain to go away! From the practitioner’s standpoint, however, it is important to determine what is causing the pain and to rule out serious and life-threatening conditions. Patients worry about how and when you will relieve their pain; practitioners are most concerned with what is causing the pain.
An entire specialty and many books are dedicated to the problems of chronic pain and pain management. However, I will leave chronic pain alone for now, and instead emphasize the importance of eliciting and documenting the key elements in the patient’s history. This is the starting point – gathering the basic data set needed to guide the diagnostic workup and formulate a differential diagnosis.
The “Magnificent Seven”
At a minimum, there are seven characteristics of pain that should be elicited from the patient, regardless of the type of pain. These “magnificent seven” characteristics are listed here. (Trivia question: Can you name the actors who starred in the original 1960 movie The Magnificent Seven? Read on for the answer.)
- Location: Where is the pain now? Where was the pain at onset? Does it radiate or go anywhere else?
- Onset: How did the pain start? Over what period of time? Was onset sudden or gradual?
- Duration: How long has the pain been present? Has it been intermittent or constant? Have there been similar episodes in the past?
- Severity: How bad is the pain now? How bad was it at onset? What was the maximum level of pain? (Use a pain scale.)
- Quality: What type of pain is it? How would you describe the pain? What does the pain feel like?
- Associated Symptoms: Are there any other symptoms besides pain? (Ask questions specific to the chief signs and complaint as listed on the documentation templates. For example, ask if the patient has abdominal pain; if so, ask about symptoms: nausea, vomiting, diarrhea, etc.)
- Modifying Factors: Does anything make the pain better? Does anything make the pain worse?
One of the most overlooked, yet most important pieces of patient history are the risk factors. Along with the magnificent seven, the risk factors provide the practitioner with valuable clues to serious causes of the patient’s condition. Each chief complaint of pain (headache, chest pain, abdominal pain, back pain, etc.) has its own list of “red flags.” It is not possible, even for the experienced clinician, to remember all of the risk factors for each chief complaint of pain. Try it yourself. If you cannot recite all of the risk factors for headache, chest pain, abdominal pain, and back pain right now from memory, then you need help! You need the help of clinical decision support contained in a templated paper or electronic medical record.
The Rest of the Story
Practitioners need “the rest of the story” in order to fully evaluate complaints of pain. The rest of the story includes:
- Past Medical History: Illnesses, conditions, hospitalizations, surgeries, and OB-GYN
- Medications & Allergies
- Personal & Social History
- Family History
Even though taking a complete history is not rocket science, chart audits continue to show that important elements of the history are simply not asked or not documented. In the event of a complication or bad outcome, all subsequent readers of the medical record will be left wondering why the standard history is absent. In the event of litigation, it will be too late to ask the patient any more questions; instead, the plaintiff’s attorney will be the one asking questions of the practitioner!
Trivia Answer: The actors in the 1960 film The Magnificent Seven were:
Yul Brynner, Steve McQueen, Brad Dexter, Robert Vaughn, Charles Bronson, James Coburn and Horst Buchholz