As a third-year student attending the Canadian College of Naturopathic Medicine in Toronto, Ontario. I am very excited to be approaching my final practical year where I will be seeing patients at the Robert Schad Naturopathic Clinic.
As much as this is a scary transition, I am also incredibly excited and eager to welcome the new challenge.
One of the first things Naturopathic Students learn when seeing a patient for any concern is to ask what their Chief Complaints are (or better known as “CC”). How do we ensure we get all the important facts and rule out red flags? I was reminded by a blog written by Jonathan Goodman from the Personal Trainer Development Center on “A Quick and Dirty Pain Assessment” and thought I’d expand on his valuable approach.
1. Start with Open Ended questions.
For example, “What brings you into the clinic today?” or “How is your sleep?”
Letting the patient talk and describe their experience in their own words is key. Open ended questions allow for an open dialogue and avoids biased and non-descriptive answers. A Closed Ended or Leading question limits the patient and is often used after open ended questions to further clarify specific details of the concern. Closed Ended questions can often be answered with one-word answers or with ‘yes/no’ responses.
For example, “Is your pain stabbing?” or “Do you wake up in the middle of the night?”
2. LO DR FICARA
LO DR FICARA is an acronym that helps to guide the practitioner in identifying all the important descriptions of each concern:
L- Location: Where is the symptom felt?
O- Onset: When did it start? Is there a correlating event? Is there a pattern to the onset (ie. time of day, after you eat, trauma)? Has this happened before?
D- Duration: How long does the symptoms last for (ie. minutes, weeks, years)?
R- Radiation/Referral: Does the physical sensations radiate or refer anywhere else in the body? What does it feel like?
F- Frequency: How often do you experience the symptom?
I- Intensity: Rating the sensation on a scale of 1-10, where 10 is the most extreme of the symptom. This is especially important because sensations are subjective and provides a numerical value to compare to in the future.
C- Characteristic: How does it feel? The more descriptive the better
A- Aggravating Factors: What makes the symptom worse (ie. damp weather, overwork)?
R- Relieving Factors: What makes the symptom better (ie. rest, heat)?
A- Associated Symptoms: Are there any other symptoms that are experienced at the same time as the Chief Complaint?
Let’s go through an example Chief Complaint of BACK PAIN:
L- location: left lower back pain (sacroilliac region) along the vertebrae and left erector muscles
O- onset: started 2 weeks ago when I was cleaning out my garage and lifting heavy boxes. I’ve never felt this before
D- duration: hurts for10- 30 min
R- radiation/referral: there is a sharp shooting pain down the back of my left leg til mid thigh
F- frequency: after I get up from sitting at my desk for more than 3 hours at a time, approximately 6 times/d
I- intensity: 4/10 generally, 7/10 during most painful moments (10 being the worst pain of my life)
C- characteristic: dull ache at all times with sharp stabbing, shooting local pain during painful movements
A- aggravating factors: standing up after sitting for >3 hours at a time, sleeping on stomach and right side, lifting heavy objects, strenuous activities
R- relieving factors: rest, sitting, lying on back, leaning to the left, heat
A- associated symptoms: tingling in the left foot
Following this protocol can help identify what issue is going on with our patients. Once a clear picture is generated, the next question is to ask if there are any “RED FLAGS” that indicate for critical or emergent actions.
For example, this patient most likely has a left sided herniated disc that is causing an impingement on the left sciatic nerve from an acute trauma while lifting a heavy object with improper form.
Following up with specific Close Ended questions and physical exams will help to Rule Out emergent cases. Never let your patients leave your office until you have clearly eliminated critical conditions and have made appropriate referrals.
Stay tuned for a follow-up post on “ASSESSING EMERGENT CASES”.
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