MED-02 — Lesson 3 of 6

OPQRST: Assessing the Active Complaint

Six questions that drive every treatment decision

BLUF: OPQRST gives structure when chaos erodes judgment. When someone has pain, shortness of breath, dizziness, or any active complaint, these six questions create a clinical picture that tells you what is happening, how serious it is, and whether it is getting worse. You are not trying to make a diagnosis — you are deciding what to do next.

The OPQRST Mnemonic

OPQRST is used to characterize any active pain or complaint. It is typically embedded within the Signs and Symptoms section of SAMPLE — when S produces a complaint, OPQRST expands it. Run through OPQRST in sequence for any new complaint, and repeat it with every reassessment.

OPQRST at a Glance

Onset — When did it start? Sudden or gradual? At rest or activity?

Provocation / Palliation — What makes it worse? What makes it better?

Quality — How does it feel? Sharp, dull, crushing, burning, tearing, pressure?

Region / Radiation — Where is it? Does it move or spread anywhere?

Severity — 0 to 10. But track the trend, not just the number.

Time — Constant or intermittent? Better, worse, or unchanged? Previous episodes?

Run through OPQRST in sequence for any new complaint, and repeat it with every reassessment to track the trend.

O — Onset

Onset — When did this begin — and what was the patient doing when it started?

Onset tells you the time course and context of the complaint. A symptom that began suddenly during exertion is clinically very different from one that developed gradually over several hours at rest.

Ask

When did this first start? (time, date if applicable)
Did it come on suddenly or gradually?
What were you doing when it began?
Were you at rest or active?

Clinical Significance

Sudden onset is more often associated with serious acute events — cardiac, vascular, or neurological. Gradual onset over hours suggests infection, inflammation, or metabolic process. Onset during heavy exertion shifts suspicion toward cardiac, musculoskeletal, or exertional causes.

P — Provocation and Palliation

Provocation / Palliation — What makes it worse — and what makes it better?

Provocation and palliation are diagnostic discriminators. They help you tell apart conditions that might otherwise look similar, and they directly guide treatment decisions — because whatever improves the complaint tells you something about its mechanism.

Ask

Does anything make it worse? (movement, breathing, eating, position, pressure)
Does anything make it better? (rest, heat, cold, specific position, not eating)
Did you take anything for it? Did it help?

Key discriminators

Worsens with deep breath — pleuritic pain (pneumothorax, pulmonary embolism, rib fracture)
Improves with leaning forward — pericarditis (cardiac sac inflammation)
Worsens with movement, improves with rest — musculoskeletal
Unaffected by position or movement — more likely visceral or internal origin
Relieved by food, worsens fasting — gastric ulcer
Worsens with food — gallbladder, pancreatitis

Q — Quality

Quality — Let the patient describe it in their own words — do not put words in their mouth

Quality is the character of the pain or sensation. The words a patient uses carry clinical weight — certain descriptors are strongly associated with specific causes. Let the patient describe it first, then offer prompts only if they cannot find words.

Key quality descriptors

Crushing, pressure, heaviness — high suspicion for cardiac ischemia
Tearing, ripping — aortic dissection until proven otherwise
Sharp, stabbing — pleuritic, musculoskeletal, or peritoneal
Burning — nerve pain, esophageal/gastric
Dull, aching — musculoskeletal, referred, or visceral
Throbbing — vascular, migraine, infection/abscess
Cramping — muscular, intestinal, uterine

Assessment Tip

Changes in quality description over time matter as much as the initial description. A pain that was dull and aching that becomes sharp and constant has likely changed in mechanism — reassess the entire OPQRST.

R — Region and Radiation

Region / Radiation — Where is it — and does it move or spread anywhere?

Region tells you the anatomical location. Radiation — where the pain spreads — is often the most diagnostically significant finding and should be explored carefully.

Ask

Where is the pain right now? (Have the patient point with one finger if possible)
Does it stay in one place or does it move or spread anywhere?
Does it radiate down an arm, up into the jaw, into the back, down a leg?

Classic radiation patterns

Left arm / jaw — cardiac ischemia (heart attack)
Between shoulder blades / back — aortic dissection, pancreatitis
Right shoulder — gallbladder, liver
Groin / flank — kidney stone
Shoulder tip — diaphragm irritation (ruptured spleen, ectopic pregnancy)
Down one leg — lumbar nerve impingement (sciatica)

Knowledge Check

A patient describes chest pain that began suddenly during a heavy pack carry. The quality is “crushing pressure.” It radiates to the left arm and jaw. Severity is 9/10 and constant. What is your highest-priority concern?

A. Musculoskeletal strain from carrying the pack B. Dehydration from exertion during the pack carry C. Cardiac emergency consistent with myocardial infarction D. Pleuritic pain from a rib injury during the carry

Field Significance

Radiation or migration of pain — especially pain that was localized and begins to spread — almost always indicates escalating risk. A complaint that is becoming more diffuse is getting worse, even if the severity score hasn’t changed yet.

S — Severity

Severity — 0 to 10 — but the trend is more important than the number

The 0-10 pain scale is useful primarily for tracking change over time. The number itself is subjective and varies enormously between individuals. What matters is whether severity is increasing, stable, or decreasing — and whether the patient’s tolerance for the pain is changing.

Ask

On a scale of 0 to 10, where 0 is no pain at all and 10 is the worst pain you can imagine — what number is this right now?
Is it getting better, getting worse, or staying the same since it started?
Is it affecting your ability to function normally?

Preparedness Principle

Track severity at every reassessment with a timestamp. Document trends, not just numbers. A patient at 6/10 who is declining toward 8/10 over two hours with increasing functional impairment is a different clinical problem than one who has stabilized at 6/10 with normal function.

Knowledge Check

Why is the trend in severity score more clinically important than the number itself?

A. Pain is subjective, but a worsening trend shows deterioration B. Higher numbers always indicate surgical emergencies C. The severity score is not useful at all in austere environments D. The number only matters once it reaches 8 or higher

T — Time

Time — Duration, pattern, and trajectory — time reveals urgency

Time has two dimensions: the duration of this episode, and the pattern of the complaint (constant vs. intermittent, and how it has changed over time). Time often determines how urgently you must act.

Ask

Is it constant or does it come and go?
How long does it last when it does come?
Has it been getting progressively worse, better, or staying the same?
Have you had this before? When? How did it resolve?

Time Reveals Trajectory

A complaint that has been constant and worsening over 8 hours is more urgent than one that is intermittent and improving. Prior episodes that resolved on their own are informative — but a complaint that is more severe or longer-lasting than previous episodes should be treated as escalating.

OPQRST Pattern Recognition

In an austere environment, pattern recognition across OPQRST elements is how you triage without diagnostic tools. The following table summarizes high-priority patterns to recognize.

Pattern	OPQRST Findings	Consider	Action
Cardiac emergency	Sudden onset during exertion; crushing, pressure quality; radiates to left arm/jaw; 8-10/10; constant and worsening	Myocardial infarction (heart attack)	Rest immediately. Aspirin if no contraindications. Urgent evacuation.
Tension pneumothorax	Sudden onset after trauma or exertion; sharp quality; worsens with breathing; unilateral chest	Pneumothorax	Needle decompression if trained. Urgent evacuation. See MED-01.
Appendicitis	Gradual onset over 6-12 hours; started central/navel, migrated to lower right; worsens with movement; 5-8/10	Appendicitis	NPO (nothing by mouth). Antibiotics if available. Evacuation — surgical emergency.
Musculoskeletal	Associated with specific activity or trauma; sharp, aching quality; worsens with movement, improves with rest; localized	Sprain, strain, fracture	Immobilize, RICE, analgesics. Evacuation if fracture suspected.
Dehydration / heat illness	Gradual onset during exertion/heat exposure; dull headache, nausea, dizziness; improves with rest and fluids	Dehydration, heat exhaustion	Shade, rest, oral hydration. Monitor for heat stroke progression.

Red Flag Patterns — Evacuate

Sudden onset + severe pain + radiation (especially cardiac pattern) | Pain that worsens with breathing | Abdominal pain with guarding or rigidity | Pain that is changing quality or migrating | Any severe complaint in a high-risk patient (cardiac history, anticoagulation, diabetes)

Knowledge Check

Abdominal pain that started around the navel and migrated to the lower right quadrant over 8 hours, worsens with movement, and is accompanied by low-grade fever should raise concern for which condition?

A. Kidney stone — kidney stones always migrate to the right lower quadrant B. Appendicitis — the classic navel-to-lower-right migration with fever C. Musculoskeletal strain — the location rules out internal causes D. Gastric ulcer — pain near the navel always comes from the stomach

Complete this lesson’s Knowledge Check to continue

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