FCMD%613!

Family.Medicine%Female.Batch.9.

OSCE%.Back.Pain.History.Taking!
Done by: Abdullah.Tammas..
..................Haya.ALOraini.
!
Revised by: Rawan.ALDahash!

References.and.for.more.details:.
.Essen&als!of!Family!Medicine!–!sixth!edi&on!!
!
 Back Pain History Taking
Differential Diagnosis:

1- Mechanical (97%): (Lumbar strain, sprain (70%) - Degenerative disk - Herniated disk (sciatica) – Vertebral
compression (osteoporosis & steroid use) - Spinal stenosis)

2- Non-mechanical (1%): (Cancer - Inflammatory arthritis - Infection → UTI, TB)

3- Visceral (2%): (Pelvic organs→ prostatitis, PID - Renal disease → renal stones, UTI (Pyelonephritis) - Aortic
aneurysm - GI → Pancreatitis, cholecystitis, peptic ulcer)

4- Psychosocial: (Depression & somatization)

1- General Pre-history taking steps:

1- Patient demographics (ID)

2- Introduce yourself
3- Obtain verbal consent
4- Setup
5- Ensure privacy and comfort.

2- Chief complaint:

Documented in the patient’s own description of the Pain & its duration

3- History of presenting illness:

• Site:
1- Where do you feel it? (Localized to the spine – paraspinous muscles…)
• Onset + timing
1- Onset: When did it start? -
2- Frequency: How many time/day?
3- Course: - Sudden - Gradual - Continuous – Intermittent
4- Duration- for how long did it last? ( Acute < 12 weeks – chronic > 12 weeks )
5- Timing: Night/day.
• Character:
1- Describe the pain? ( dull – sharp – burning – altered sensation – pain like electric shock)
• Radiation:
1- Does the pain radiate anywhere? ( buttock “ lumbar strain” – down below the knee “ herniated disc” – saddle
anesthesia and bilateral pain “ cauda equine syndrome” )
• Exacerbation + Relieving:
1- Exacerbating factors (Valsalva – coughing – bending forward – with exercise – walking downhill)
2- Relieving factors: (over-the-counter medications – massage – stretching - acupuncture – heat – ice – certain
positions)
• Severity:
1- Quantify pain using the pain scale “On a scale of 1 to 10; 1 being very mild pain and 10 being the worst pain
imaginable, how would you classify your pain?”
2- Does the pain interfere with your daily activity?
 • Associated symptoms:
1- Constitutional symptoms: Night sweating, ↓ appetite, weight loss, fatigue, fever.
2- Neurological: lower limbs weakness/ pain, loss of sensation, ↓ motion, urinary & bowel incontinence.
3- Morning stiffness relived by activity → ankylosing spondylitis.
4- Psychosocial → depression & somatization.
5- Infections : fever, vertebral tenderness, recent infection, UTI (urgency, frequency, painful urination)
6- GI symptoms → abdominal pain.

• Red Flags:

4- Past medical History:

1- History of trauma
2- Previous problem in the past.
3- Chronic diseases: (HTN, DM, Dyslipidemia).
4- Osteoporosis / bone disease.
5- Infections: (TB).
6- Psychiatric disease: (depression & anxiety.

5- Drug/Allergy History:

1- Medication use or overuse (chronic steroids use – NSAIDs…)

2- Allergies

6- Family history:

1. Ask about the presence of a similar problem in the family.

2. Any disease that runs in the family?
3. History of Osteoporosis.
7- Social history:

Occupation - Marital status - Smoking - Drug abuse and alcohol abuse - Any stress in life .

8- “Don’t forget” ICE

! I → Idea about the causes of the symptoms.

! C → Concerns about the symptoms & its complication.
! E → Expectation from the Dr. (Medications, tests).

9- Systematic Review

10- Thank the PT