I usually follow the NLDOCATS routine when talking to a patient
Nature
Location
Duration
Onset
Course
Aggravating factors
Treatments
Special/Other
Always start by writing the Age and Gender.
Example: Joe is a 34 year old male who complains of...
Nature: What is the problem? Example: ankle fracture, foot pain, leg pain, toe pain, nerve pain....
Location: Be as precise as possible: Medial/Lateral, Left/Right, Dorsal/Plantar, name of tendon
Duration: How long has this been going on?
Onset: Was there any recent trauma? Did you just wake up with it? Was there a history of prior injuries or pains?
Course: Getting worse, better, same?
Aggravating factors: What makes it worse? What makes it better?
Treatments: Has anything at all been tried? Medication, splints, braces, therapy, other doctors?
Special/Other: Change in activities? Shoes? Run more? Run faster? Really anything else to fill in the gaps of the story.
This is a great way to obtain a detailed history.
Joe is a 34 y/o male who presents c/o pain in the left foot at the 3rd interspace. Feels like a sharp pain that radiates to his 4th and 3rd toes. Sometimes he notes a clicking. The pain has been present for about 6 months. Denies any history of injury. It has been getting worse the last few weeks. Pain is relieved with rest. Notes that he has increased running lately. Has been doing more business meeting in a dress shoe. Has tried Motrin with no relief of symptoms. Has not seen a doctor in the past.
Diagnosis?
Most likely a neuroma.
