How to take complete history according to oldcaarts and complete physical examination

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OLDCAARTS mnemonic history taking onset location duration character aggravating alleviating relieving timing severity

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History Taking (OLDCAARTS) and Complete Physical Examination

Part 1 — The Complete Medical History

A complete history-and-physical (H&P) follows a standardized format. The sections below are drawn from Neuroanatomy through Clinical Cases (3rd ed.), Goldman-Cecil Medicine, and Kaplan & Sadock's Synopsis of Psychiatry.

1. Chief Complaint (CC)

A succinct, 1–2 sentence statement — ideally in the patient's own words — that captures:

Patient's age and sex
Primary presenting problem
Relevant brief context

Example: "A 53-year-old man with known hypertension presenting with crushing substernal chest pain of 1 hour's duration."

2. History of Present Illness (HPI) — Use OLDCAARTS

The HPI is the chronological, detailed narrative of the current problem. Use the OLDCAARTS mnemonic to ensure nothing is missed:

Letter	Element	Key Questions
O	Onset	When did it start? Was it sudden or gradual? What were you doing when it began?
L	Location	Where exactly is the symptom? Can you point to it? Does it radiate or spread?
D	Duration	How long does it last? Is it constant or intermittent?
C	Character	What does it feel like? (sharp, dull, burning, throbbing, pressure-like, cramping)
A	Aggravating factors	What makes it worse? (movement, eating, exertion, position, stress)
A	Alleviating/Relieving factors	What makes it better? (rest, medications, heat/cold, eating)
R	Radiation	Does the symptom travel anywhere? (e.g., arm, jaw, back, groin)
T	Timing	When does it occur? Any pattern? (morning, postprandial, nocturnal, with exertion)
S	Severity	On a scale of 0–10, how bad is it? How does it affect daily activities?

Important: Always include pertinent negatives — symptoms that are absent are as diagnostically valuable as those present. Prior episodes, prior treatment, and the effect on function should also be documented.

3. Past Medical History (PMH)

Prior medical illnesses (chronic conditions: DM, HTN, asthma, CAD, CKD, etc.)
Prior surgical and procedural history (with dates)
Prior hospitalizations
Childhood illnesses
Obstetric/gynecologic history (in women): gravida, para, last menstrual period

4. Medications and Allergies

All current medications: prescription, over-the-counter, vitamins, herbal supplements — include dose, route, and frequency
Allergies: document the specific reaction (e.g., hives, anaphylaxis, rash), distinguish true allergies from intolerances (e.g., GI upset from NSAIDs)
Document NKDA (no known drug allergies) if applicable

5. Family History (FHx)

Health status and cause of death of first-degree relatives (parents, siblings, children)
Familial diseases relevant to the HPI: premature cardiovascular disease, DM, cancer, genetic disorders, psychiatric illness, autoimmune conditions
A family tree (genogram) format is concise and clear

Example: "Mother died at 64 of MI, had HTN. Father had MI at 52 and DM, died at 73 of stroke. One sibling, healthy."

6. Social and Environmental History (SocHx)

Occupation and occupational exposures
Living situation: who lives with the patient, housing conditions
Marital/relationship status, dependents
Travel history (domestic and international)
Sexual history: orientation, partners, contraception, STI risk
Habits:
- Tobacco: type, pack-years, current/former/never
- Alcohol: type, quantity, CAGE/AUDIT screen
- Illicit drugs or substance use
- Physical activity and diet
Military service history (screen for PTSD if applicable)
Educational background and health literacy

7. Review of Systems (ROS)

A systematic, head-to-toe inquiry to identify problems not covered in the HPI. If something relevant surfaces, move it to the HPI. Key systems to cover:

System	Symptoms to Screen
Constitutional	Fever, chills, fatigue, weight loss/gain, night sweats
HEENT	Headache, vision changes, hearing loss, tinnitus, epistaxis, dysphagia, sore throat
Cardiovascular	Chest pain, palpitations, dyspnea on exertion (DOE), orthopnea, PND, edema, syncope
Respiratory	Cough, sputum, hemoptysis, wheezing, dyspnea
GI	Nausea, vomiting, dysphagia, heartburn, abdominal pain, bowel habit changes, rectal bleeding, jaundice
GU	Dysuria, frequency, hematuria, urgency, incontinence; for men: erectile dysfunction
OB/GYN	LMP, menstrual irregularity, vaginal discharge, menopausal symptoms
Musculoskeletal	Joint pain/swelling, stiffness, back pain, muscle weakness
Neurological	Headache, dizziness, seizures, weakness, numbness/tingling, memory changes
Psychiatric	Depression, anxiety, sleep disturbance, suicidal ideation
Dermatologic	Rashes, lesions, pruritis, hair/nail changes
Hematologic/Oncologic	Easy bruising, bleeding, lymphadenopathy, prior malignancy
Endocrine	Polyuria, polydipsia, heat/cold intolerance, weight changes
Immunologic/Infectious	Recurrent infections, HIV risk, immunosuppression

Part 2 — Complete Physical Examination

The physical examination proceeds head to toe and is documented systematically. Based on Neuroanatomy through Clinical Cases and Goldman-Cecil Medicine:

1. General Appearance

Level of alertness and orientation
Apparent age vs. stated age
Nutritional status (cachectic, obese)
Distress level: "Patient appears in mild/moderate/severe distress"
Skin color: pallor, jaundice, cyanosis, flushing
Gait and posture
Hygiene and grooming

2. Vital Signs

Parameter	Normal Range
Temperature	36.1–37.2°C (97–99°F)
Heart rate (HR)	60–100 bpm
Blood pressure (BP)	<120/80 mmHg
Respiratory rate (RR)	12–20 breaths/min
SpO₂	≥95%
Weight / BMI	Document; calculate BMI
Height	Document
Pain score	0–10 scale

Measure BP in both arms if aortic dissection or coarctation suspected; check for pulsus paradoxus (>10 mmHg drop in systolic BP during inspiration — suggests tamponade).

3. HEENT (Head, Eyes, Ears, Nose, Throat)

Head: Skull shape, tenderness, hair distribution, scalp lesions

Eyes:

Visual acuity (Snellen chart)
Pupils: size, symmetry, reactivity (PERRLA)
Extraocular movements (EOMs intact?)
Conjunctiva and sclera: injection, jaundice, pallor
Fundoscopy: disc margins, AV nicking, hemorrhages, exudates, papilledema

Ears:

External auditory canal and tympanic membranes (otoscope)
Hearing: whisper test or Weber/Rinne tuning fork tests

Nose:

Mucosa, septum, turbinates, discharge, polyps
Sinus tenderness (maxillary, frontal)

Mouth/Throat:

Lips, mucosa, teeth, gums
Tongue, palate, uvula
Tonsils (erythema, exudate, enlargement)
Gag reflex

4. Neck

Lymphadenopathy (cervical, submandibular, supraclavicular)
Thyroid: size, texture, tenderness, nodules
Tracheal position (midline?)
Carotid bruits (auscultate)
Neck stiffness/meningismus (Kernig/Brudzinski if meningitis suspected)
JVD (jugular venous distention): measure JVP at 45° — normal <3 cm above sternal angle

5. Lymph Nodes

Systematically palpate all accessible nodal chains:

Cervical, submandibular, preauricular, occipital
Supraclavicular (Virchow's node)
Axillary
Inguinal

Document: size, consistency (firm/rubbery/soft), tenderness, fixation

6. Back and Spine

Spinal curvature (scoliosis, kyphosis, lordosis)
Tenderness: vertebral, paraspinal, CVA (costovertebral angle)
Range of motion

7. Chest and Lungs

Inspection: Shape (barrel chest?), symmetry of expansion, use of accessory muscles, intercostal retractions

Palpation: Tactile fremitus, tracheal position, rib tenderness

Percussion: Resonant (normal), dull (consolidation, effusion), hyper-resonant (pneumothorax, emphysema)

Auscultation: Breath sounds (vesicular, bronchial, bronchovesicular), adventitious sounds:

Crackles (fine/coarse) — fluid or fibrosis
Wheezes — airflow obstruction
Rhonchi — secretions
Pleural rub

8. Cardiovascular / Heart

Inspection: Precordial pulsations, visible PMI

Palpation:

PMI (point of maximal impulse): normal at 5th ICS, MCL
Thrills (palpable murmurs)
Heaves

Auscultation (all four areas + Erb's point):

S1 and S2: intensity, splitting
Extra sounds: S3 (ventricular gallop → HF), S4 (atrial gallop → stiff ventricle)
Murmurs: grade (I–VI), location, radiation, timing (systolic/diastolic), quality

Peripheral vascular:

Pulses: radial, carotid, femoral, popliteal, dorsalis pedis, posterior tibial — rate, rhythm, amplitude
Capillary refill time (<2 sec normal)
Peripheral edema: pitting vs. non-pitting, extent

9. Abdomen

Inspection: Contour (flat, scaphoid, distended), visible pulsations, surgical scars, hernias, skin changes (caput medusae, striae)

Auscultation (before palpation):

Bowel sounds: present/absent, frequency, quality
Bruits (renal, aortic)
Venous hum

Percussion:

Liver span (normal: 6–12 cm at MCL)
Splenic dullness (Traube's space)
Shifting dullness / fluid wave (ascites)
Tympany (bowel) vs. dullness (solid organs)

Palpation (light then deep):

Tenderness: location, guarding, rigidity
Organomegaly: hepatomegaly, splenomegaly
Masses: location, size, consistency
Murphy's sign (RUQ), McBurney's point (RLQ), Rovsing's sign
Renal angles

10. Extremities

Inspection: swelling, deformity, skin changes, nail changes (clubbing, koilonychia, leukonychia)
Palpation: joint tenderness, warmth, effusion
Peripheral edema grading (1+–4+)
Calf tenderness (Homan's sign — low sensitivity)
Peripheral pulses (as above)

11. Neurological Examination

Mental status:

Orientation (person, place, time)
MMSE or MoCA if cognitive impairment suspected
Mood and affect

Cranial nerves (CN I–XII):

CN I: olfaction
CN II: visual acuity, visual fields, pupillary light reflex
CN III/IV/VI: EOMs, ptosis, pupil size
CN V: facial sensation, jaw movement, corneal reflex
CN VII: facial symmetry, taste (anterior 2/3 tongue)
CN VIII: hearing (Weber/Rinne)
CN IX/X: gag reflex, palate elevation, voice quality
CN XI: SCM and trapezius strength
CN XII: tongue protrusion (midline?)

Motor:

Tone (normal, spastic, rigid, flaccid)
Bulk/atrophy
Strength: 0–5 scale, proximal and distal, all limbs

Reflexes (Deep Tendon Reflexes):

Reflex	Root
Biceps	C5–C6
Brachioradialis	C5–C6
Triceps	C7
Patellar	L4
Achilles	S1

Grade: 0 (absent) to 4+ (hyperreflexia with clonus); normal = 2+
Plantar response: flexor (normal) vs. extensor (Babinski — UMN lesion)

Sensory:

Light touch, pain/temperature, vibration, proprioception
Cortical: 2-point discrimination, stereognosis, graphesthesia

Coordination:

Finger-nose test, heel-shin test, rapid alternating movements
Romberg test (eyes open vs. closed)

Gait: Normal walking, tandem gait, heel walking, toe walking

12. Skin (Dermatologic)

Inspect entire skin surface
Color, texture, turgor, moisture
Document any lesions: type (macule, papule, vesicle, pustule, plaque, etc.), distribution, size, color, borders, associated features

13. Breasts (Females and Males)

Inspection: symmetry, skin changes, nipple discharge/inversion
Palpation: all quadrants, axillary tail; note any lumps — consistency, mobility, tenderness

14. Genitalia and Rectum

Males:

Penis (phimosis, lesions, discharge)
Testes and epididymis (size, tenderness, masses)
Inguinal hernia (Valsalva maneuver)

Females:

External genitalia (Bartholin's glands, vulva, vaginal introitus)
Speculum exam: cervix (lesions, discharge), Pap smear
Bimanual exam: uterus (size, position), adnexa (masses, tenderness)

Rectal exam (all patients):

Perianal inspection (hemorrhoids, fissures)
Sphincter tone
Stool: blood on glove
Males: prostate (size, consistency, tenderness)
Females: posterior vaginal wall

Documentation Summary

The final H&P note should include:

CC → 2. HPI (OLDCAARTS) → 3. PMH → 4. Medications & Allergies → 5. FHx → 6. SocHx → 7. ROS → 8. Physical Exam (head to toe) → 9. Labs/Investigations → 10. Assessment & Plan

Sources:

Neuroanatomy through Clinical Cases, 3rd ed. — Goldman & Bhatt (Chapter 1: H&P Format)
Goldman-Cecil Medicine, International Edition — Table 6-1: Patient's Medical History; Physical Examination
Pfenninger and Fowler's Procedures for Primary Care, 3rd ed. — ROS and Physical Evaluation templates
OLDCAARTS mnemonic — standard clinical education framework (Lecturio, OnlineMedEd)

For pediatrics patient

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