Listen to the patient. He is telling you the diagnosis.

Doctors need to have a logical approach so that no vital clue is overlooked and an accurate diagnosis is made as quickly as possible. Of course, physicians must individualize their approach to different patients based on the clinical scenario, while trying not to let other factors, such as a bad mood or lack of sleep, influence our problem solving or decision making. The best doctors try to avoid this at all costs. Let me explain how we approach a patient.

 Listen to the patient. He is telling you the diagnosis.

This tenet is credited to none other than Sir William Osler (1849-1919), the founding father of modern medicine. Despite the then unimaginable advances in medicine over the next 100 or so years, this axiom still holds as true, if not truer, today as it did back in Sir Osler's time. Listen to the patient.  What a basic communication concept. You've probably heard the old saying that it's why you have two ears and only one mouth. We're supposed to listen more than we talk, and in medicine, this is a key concept when taking a patient history. We're not so good at it though. On average, a doctor interrupts his patient after about 23 seconds. No wonder patients complain that their doctor didn't listen to them.

Listen to the patient. He is telling you the diagnosis.

Of course, this doesn't mean that the patient will literally tell me, "Hey, doc, I've got a left lower lobe pneumonia caused by Streptococcus pneumoniae." But what it does mean is that the patient will provide doctors with enough clues to make the diagnosis, sometimes even before we examine them. Obviously, there are times when we simply have to look in the child's ear to determine whether or not an ear infection exists. However, in many other circumstances, we can usually make an accurate diagnosis, or come up with a good list of possible diagnoses, by simply listening to the patient, letting them tell us all the details, and asking specific questions to fill in any missing information. It is foolish for a doctor to skimp on taking a good history in the interest of time. Attempting to make a diagnosis based on an incomplete history leads to a less focused approach to the problem, more laboratory and imaging tests, and sometimes, a delay in diagnosis and treatment.

 When taking a history from the patient, the doctor needs to know several key pieces of information, which are easy to remember as "OPQRST." Practically every medical student learns to take a history this way, but I've added a "U" to it. So, here's what "OPQRSTU" means:

"O" is for onset. When exactly did the problem start? Two months ago or last week?

"P" refers to provoking or palliating features. For example, does walking up the stairs make your chest pain worse? Does an over-the-counter anti-inflammatory help your joint pain?

"Q" is for quality. What's the quality of your abdominal pain? Is it cramping, a dull ache, or sharp and burning?

"R" means radiation. Does your chest pain radiate to your arm? Does your abdominal pain go to your back?

"S" is for site. Where exactly is your abdominal pain? Is it in the middle by your belly button or is more by the left side?

"T" refers to timing. Does your abdominal pain flare up every time you eat? Is your joint pain worse in the morning ond does it improve through the day?

"U" is my own addition to this traditional medical school mnemonic. Since we're in the Midwest with dairy farms, "U" stands for udder, which sounds like "other". Are there any other associated signs and symptoms? Most of the time patients will tell us their other associated symptoms on their own. For example, a patient will inform us that her chest pain is associated with shortness of breath, nausea, and sweatiness.

But other times, the patient may not connect pertinent "other" symptoms with the main complaint. Here's an example. Let's say a patient complains about low back pain that radiates down the legs and causes some numbness in the legs as well. What the patient may not think is important, and may be too embarassed to mention, is that for the past two weeks, she's been wetting the bed at night, something she hasn't done since she was three years old. Losing urine, or urinary incontinence, when associated with low back pain can be a sign of an impingement on the spinal cord and is a serious problem.

Another example is the 79 year old man who complains of shortness of breath. He doesn't think to mention the black tarry stools he's been having for a few months now. Why in the world would that be related to his shortness of breath? The black stools are from blood in the intestines. That blood is coming from a gastric ulcer taking too many over-the-counter aspirins for his arthritis. The loss of blood has caused a significant anemia and the lack of oxygen-carrying red blood cells is making him short of breath. That's an important "other" symptom. 

Why is this important to you? You are in a key position to help us make the diagnosis. Giving the doctor a clear, thorough, and well-organized history is vital to figuring out what's wrong. Use "OPQRSTU" as a tool to assist you in telling your story. Your doctor will think you've gone to medical school.