Expansion
Site, Onset, Character, Radiation, Associations, Time course, Exacerbating factors, Severity
Expansion
- S - Site: where exactly, and can it be pointed to with one finger
- O - Onset: sudden or gradual, what the patient was doing, and how quickly it reached maximum
- C - Character: sharp, dull, burning, crushing, colicky, tearing
- R - Radiation
- A - Associated symptoms: nausea, sweating, breathlessness, fever
- T - Time course: duration, constant or intermittent, pattern through the day
- E - Exacerbating and relieving factors, including the response to analgesia
- S - Severity, scored out of 10, and its effect on function and sleep
Discriminating patterns
- Sudden maximal onset: subarachnoid haemorrhage, aortic dissection, perforation, pulmonary embolism
- Tearing to the back: aortic dissection
- Colicky: obstruction of a hollow viscus
- Relieved by sitting forward: pericarditis, pancreatitis
- Worse on inspiration: pleuritic
Pain out of proportion to the signs is a specific red flag, suggesting mesenteric ischaemia, necrotising fasciitis or compartment syndrome.
Always ask what the patient thinks is causing it, and what they are worried about.