This guide addresses the ‘S‘ubjective portion of a Problem-Focused SOAP Note.

Primary History

Always start with the standard questions applied to the patient’s Chief Concern(s):

1. Location/Radiation
   
2. Quality/Severity
   
3. Duration (total/episode)/Frequency
   
4. Aggravating/Relieving Factors
   
5. Associated Symptoms/Effect on Function
   

Pearls

• Note that these elements are paired to make them easier to remember.
  
• Repeat this series of questions for each concern. Ask one question at a time; avoid multi-part questions.
  
• Some questions won’t work in certain situations, for example fatigue doesn’t have a location.
  
• Record the information as objectively as possible without interpretation. Avoid medical jargon unless the patient uses it.
  
• Quote the patient directly as needed, "my teeth itch," for example.
  
• There are two durations to consider: the total illness and, if symptoms are episodic, the duration of a typical episode.
  
• Pay close attention to the time course of the symptoms. Has the symptom complex changed over time? This is particularly important with neurologic, chest, and abdominal diseases.
  

Secondary History

It is useful to think of the secondary history as a Focused Review of Systems (ROS). These questions often bring out information that supports a certain diagnosis or helps gauge the severity of the disorder. Unlike the primary history, a certain amount of interpretation (and experience) is necessary. The following list should serve as a guide to get you started. It is, of necessity, incomplete.

Fatigue

    Have the patient clarify exactly what they are experiencing.

    Ask about sleep. What is their "normal" pattern? Has this changed?

Fever

    Have they actually measured their temperature or just felt "hot?"

    Ask about chills or sweating.

Headache

    Be sure you understand the time course of the symptoms.

    Ask about nausea and vomiting.

    Ask about visual changes.

    Ask about the relationship with stress, work, week-ends, and emotions.

Eye Problems

    Ask about visual changes, loss of vision, blurring, or double vision

    Ask about spots, "floaters," or flashing lights.

Ear Problems

    Ask about hearing loss or ringing in the ears.

    Ask about dizziness or vertigo.

    For hearing loss, ask if they are having trouble understanding speech.

    Ask if anything has come out of the ear.

Nose Problems

    Is there is a seasonal pattern to the symptoms?

    Ask about associated itching, especially the of the eyes.

Chest Pain

    Ask about palpitations (awareness of heart beating), rapid pulse, or skipped beats.

    Has there been any shortness of breath? Is there any change when the patient lays down or sleeps? Does the patient sleep propped up on pillows or semi-upright in a chair?

    Ask if there is a relationship to activity. Has there been a change in exercise tolerance?

    Ask about swelling of the legs.

Cough

    Is the cough productive of sputum? What amount? What color is it?

    Has there been any blood?

Abdominal Pain

    Be sure you understand the time course of the symptoms.

    Ask about nausea, vomiting, or loss of appetite.

    Ask about urinary symptoms. Has the urine changed color?

    Ask about bowel habits. Have they changed? Is the stool black?

Joint Pain

    Is there any associated redness, swelling, heat, or loss of function?

    Ask about morning stiffness.

    Ask about joint clicking or locking.

Musculoskeletal Injury

    Ask precisely how the injury occured.

    Ask about loss of function, onset of swelling, and initial treatment.

Tertiary History

The tertiary history brings in elements of the Past Medical, Social and Family History that have bearing on the patient’s condition. By the time you get to the tertiary history you may already have a good idea of what might be going on. (This will be fine tuned by the physical exam.) Here are some examples:

Any HEENT or Chest Disorder

    Does the patient smoke? How much? How long?

    For children, does someone smoke in the home?

High Blood Pressure

    How much alcohol does the patient consume?

Breast Problems

    Is there a family history of breast cancer?

Depression

    Has the patient attempted suicide in the past?

    Has the patient been hospitalized in the past?

Abdominal Pain

    Does the patient smoke? How much? How long?

    How much alcohol does the patient consume?

    Prior surgery? Has the appendix been removed?

Chest Pain

    Does the patient smoke? How much? How long?

    Did the patient’s parents die of a heart attack? At what ages?

Note: I created this guide in 1996 to assist students who were learning the basic medical interview. I’ve refreshed it here for a new generation of learners. RR