SOCRATES

Severity

Exacerbating & relieving factors

Time

Associated features

Radiation

Onset

Character

Site

S

T

A

C

O

R

E

S

Exacerbating & relieving factors

Many common conditions which cause pain have paricular exacerbating or relieving factors. Learning these patterns of symptoms can help you make diagnosis. Click the red question mark for examples.

Example 1: Ischaemic pain in the legs, caused by peripheral vascular disease is often exacerbated by elevating the legs and relieved by sitting with them down. Example 2: The pain of peptic ulcer disease is often relieved by eating.

Character

How a patient describes their pain can help you understand the underlying pathological cause e.g cardiac pain is often described as a 'heaviness' in the chest. It may also tell you how the pain is affecting the person.

Listen to the words the patient uses when speaking about their pain to help you understand the impact, their ability to cope and the emotional response to the pain. e.g 'unbearable' , 'I can't stand it', 'it's just there all the time'

Time

When did the pain start?Is it still present or has it stopped? How long did it last for? Is it coming and going?

Time of onset may be very important in considering the timing of your tests e.g. when to take cardiac troponin blood test in relation to the time of onset of chest pain

It is important to know if the pain is still present or not so that you can treat it. e.g opiate analgesia for acute abdominal pain. Or treatment for the underlying cause of the pain e.g. GTN spray in angina.

How long the pain is there for and if it is coming and going help you to further understand the quality of the pain. e.g the pain of renal colic often comes in waves

Radiation

Asking specifically about where the pain radiates to can again help narrow the differential diagnoses. You will learn about the various patterns of pain for many diagnoses as you progress through the course. For some common examples click the red question mark

Cardiac chest pain - radiates to jaw and left arm Biliary pain - radiates to right shoulder tip Pancreatic pain - radiates through to the back

Site

Clarifying where the pain is and relating this to human anatomy will help you to narrow down the cause of the pain

Asking the patient to show you where the pain is on their body can be really helpful in the consultation

Inf

Onset

To help you reach the diagnosis, try to establish

• how the pain started
• what the person was doing at the time

Was the onset during rest or activity? What type of activity? Was a particular movement involved e.g bending forward during the onset of back pain

A sudden onset pain can indicate a sudden pathological process such as embolus, haemorrhage or perforation. A more gradual onset may indicate an inflammatory process

Info

Severity

Understanding how severe a patients pain is will help you to:

• Consider the differential diagnosis
• e.g. very severe right iliac fossa pain would point you more towards appendicitis than constipation
• Appropriately choose analgesia to treat the pain
• e.g. a patient presenting with acute onset 10/10 pain is unlikely to have satisfactory pain relief from paracetamol

Use visual pain assessment scales to help patients describe their severity Click the link below for some examples British pain society pain scales in multiple languages

Associated features

Patients with acute pain often experience associated symptoms due to the body's stress reponse to pain e.g tachycardia, nausea, sweating and raised respiratory rate. Other associated symptoms may help you to narrow your differential diagnoses, for example if they are associated with a particular body system click the red question mark for examples

Burning pain on micturition with associated haematuria may be due to a urinary tract infection. Pleuritic chest pain with associated cough and sputum production may indicate a lower respiratory tract infection or pneumonia.