By tradition, every medical visit has a common structure.
Im sure you recognize the basic design. You present your problem. Your doctor asks you questions about it then does a focused physical examination, makes a diagnosis and comes up with a plan for further tests or treatment.
This four-part structure is summarized in your medical records. In your family doctors charts, a common format for visit entries uses the acronym SOAP that stands for subjective, objective, assessment and plan.
This form of record keeping helps anyone reading the chartfor example, a physician filling in for your doctor or any other health care provider youve authorized to give you careto understand the thinking processes of your physician, how the diagnosis was determined and what the treatment plan is.
Familiarity with this traditional process can help you understand the pace and flow of each medical visit and as well see in upcoming columns, improve communication and satisfaction in your interactions with your physicians.
When you present to your doctor a medical problem, such as abdominal pain, you might have a clear idea of what the cause might be. Though your doctor will keep your diagnosis high on the list of possible diagnoses (known as the differential diagnosis), the history, examination findings and the results of investigations will narrow the list of possible diagnoses to the most likelyand hopefully the correctdiagnosis.
The history begins with your description of your symptoms. When they began and how they have changed over time. Once youve initially presented these symptoms, your doctor will ask you more detailed questions that can flesh out crucial details that may distinguish a number of different causes.
What makes your symptoms better? What makes them worse? If you are experiencing pain, does it start in one place and radiate to another area? What type of pain is it (squeezing, sharp, crampy, burning or achy)?
This question can be challenging for some to answer. To many, pain is just pain. If you havent experienced a variety of different types of pain, it might be hard to distinguish the different types. Its not unlike being an inexperienced wine taster and not being able to distinguish such subtleties.
Language and culture also influence your description.
Pain due to gastroenteritis, periods and labour are described as crampy. Pain from the passage of kidney and gall stones is typically colicky. Angina or chest pain from narrowed coronary arteries is typicallybut not alwayssqueezing.
With angina, discomfort may radiate into the throat and neck or to either arm. Here typical exacerbating and alleviating factors are very important. Angina typically comes on with anything that increases the work of the heart, such as exertion (exercise) and anxietyin short, physical or emotional stress.
Are there other symptoms associated with your primary symptom?
Nausea or queasiness is commonly associated with angina. In some cases, it may be the only symptom. Patients may experience nausea with exertion and acute stress without the typical chest pain.
Thats whyto you and your doctorshistory is so important.
Next: the doctors inquisitionwhy we ask questions the way we do.
Dr. Davidicus Wong is a family physician. His Healthwise column appears regularly in this paper. You can find his Positive Potential Medicine podcasts at wgrnradio.com.
