The MnemonicWhen I was in medical school one of the most useful mnemonics for uncovering the reason for someone’s pain was "SOCRATES". Asking if someone is in pain only gives you so much information. However, when you dive into the symptomatology of that pain it allows the astute clinician to develop a differential diagnosis (ie: a list of all possible diagnosis that could explain the symptom), which will aid in deciding upon the appropriate treatment and testing.
So what does the mnemonic SOCRATES stand for? Let’s go letter by letter…
The first “S” stands for “site”. What body part or parts are involved? Is the pain in the leg? Is it in the head? Is it a general sense of overall discomfort? The site of pain helps you fine tune your subsequent physical exam and diagnostic decision making.
The next letter is “O”, which stands for “onset”. When did the pain start? Asking about the onset is extremely important! For example, if someone has had chronic low back pain for 10 years that invokes a much lower sense of urgency than someone complaining of the sudden onset of severe belly pain or headache.
“C” stands for “characteristics”. What are the characteristics of the pain? You want the patient to describe the pain in their own terms without swaying them too much. The pain may be sharp, dull, heavy, etc. or a combination of descriptors.
The next letter is “R”, which represents “radiation”. I typically ask if the pain stays at the site they are describing or if it travels somewhere else in the body. For example, someone with chest pain radiating to the arm might be experiencing a heart attack. Back pain that is associated with radiation down the leg might indicate a herniated lumbar disc that may require surgery.
“A” stands for associated symptoms. What other symptoms are present and associated with the pain? For example, if the patient is complaining of belly pain do they also have nausea and/or vomiting? If they have a headache do they also complain of double vision or photophobia (ie: discomfort when light enters the eye)? Associated symptoms can provide a wealth of information to help you hone your differential diagnosis even more.
"T" stands for timing. When does the pain occur? Does it happen at specific times of the day, or is it constant? Does it happen during a certain movement? All of these can clue you in to the cause of the discomfort.
The letter “E” represents “exacerbating” factors; grouped within this is also alleviating factors. The patient should be probed as to what makes their pain better or worse. Certain physical positions, medications, etc. may make the pain better or more unbearable. These factors can all provide historical clues about the root cause.
The final “S” stands for “severity”. In most hospitals this is formulated on a 1 to 10 scale with 10 being the most severe pain they’ve ever experienced. This can be a tricky one to gauge because many patients will describe 10 out of 10 pain when they are lying comfortably in bed; therefore, it is often necessary to ask more pointed questions and place pain in a context.
Overall, the answers obtained when using the mnemonic SOCRATES can provide a solid framework from which to order new testing and treatments.