If you are like me, then you probably have trouble staying organized while obtaining a problem-focused history. I have found that I must rely on frameworks and schemas to keep all the information straight. The framework I use most often is the mnemonic “OLD CARTS.” It stands for Onset, Location, Duration, Character, Aggravating/Alleviating factors, Radiation, Timing, and Severity. Let’s break it down!
Say you are in the emergency department and a patient presents with abdominal pain. Your mind races as you try to remember the anatomy, pathology, physical exam findings, lab tests, etc. Where do you even begin? The first piece of information I like to know is when was the ONSET of the pain? Has it been going on for just a day? Or is it a more chronic issue? Remember our previous discussion on problem representations and goal directed history taking? A problem representation is the patient’s demographics, chief complaint, and the time course of the chief complaint. By remembering to ask about ONSET, you already have one piece of the problem representation!
This one is pretty straight forward. Simply ask the patient where the pain is located. I have found that asking them to point to the pain with one finger to be helpful.
How long does the pain last? At first, this may seem like it is the same as onset, but can you think of a scenario when duration may be different from onset? Say a patient presents to the emergency department with substernal chest pain that started 3 months ago. It has never lasted more than a few seconds and only happened when they were carrying laundry upstairs and got better when they rested. Now, the pain has been constant for the past hour. Understanding the duration as well as the onset helps tease out acute pain vs. acute on chronic pain.
The way to obtain this information is to ask, “Can you describe the pain?” Is the pain sharp, dull, aching, throbbing? Say a patient with a history of migraines presents with a headache. It is crucial to determine if this is the same pain they experience with their migraines or if it is different. Knowing the character of the pain could be the difference between treating them for a migraine or a sub-arachnoid hemorrhage.
Ask the patient if they have found anything that makes the pain or symptoms better or worse. For example, a patient with lower back pain that is made better by leaning forward on their shopping cart may have spinal stenosis. Or a patient who breathes more comfortably while propped up in a recliner instead of lying flat may have heart failure. You can also ask about the use of any over the counter medications such as NSAIDs, decongestants, or antacids.
Does the pain radiate to any other locations? What if a patient has severe epigastric pain that radiates to the back? You are halfway to diagnosing acute pancreatitis according to the Atlanta Criteria. You check a lipase and it is 5 times the upper limit of normal. It’s a slam dunk. You give them aggressive fluid resuscitation, pain control, advance their diet and discharge them in two days. Asking about radiation also triggers you to remember about referred pain. For instance, cholecystitis may have referred pain to the shoulders and inferior myocardial infarctions can present as abdominal pain.
Knowing the context of the symptoms is crucial. Ask the patient, “When do you experience the pain or symptoms?” If a patient presents with dyspnea, are they short of breath with rest or exertion? Do they have abdominal pain when they eat or is it unrelated to meals? Do they have upper extremity weakness when reaching for things in their cabinet?
This may be the trickiest pieces of information to gather. Pain severity is incredibly subjective and pain scores are often unreliable. Some people may downplay the amount of pain they are experiencing while others may overexaggerate their symptoms. I use this part of the mnemonic to simply look at the patient. Do they appear uncomfortable or in distress? Are they tachycardic and hypertensive breathing 25 times per minute? Again, the context of the complaint is crucial.
For me, OLD CARTS is tried and true. I use it for practically every patient. Early on, it may be most helpful to go in order. As you become more comfortable taking histories, you will learn to let the conversation flow naturally.
I hope you find OLD CARTS as useful as I have!
Do you use OLD CARTS or do you have a different framework for organizing your history of present illness? Share your thoughts below.