Back Pain History Taking | OSCE Tips

Back pain history taking is a crucial skill that is frequently tested in OSCEs. This tutorial offers a methodical way to collect a back pain history during an OSCE.

Presenting complaint (PC): 

What brought you here today? 

History presenting complaint (HPC):

Site: Can you tell me where you feel the pain?

Onset: when did it start? (sudden or gradual)

Character: can you tell me how it feels? ( Aching, throbbing, shooting) 

Radiation: does the pain move anywhere else? Does it move to your leg? 

Associated symptoms: Stiffness/deformity, trauma, numbness, incontinence, bladder dysfunction, weight loss, redness, swelling, rash, fever, weakness, night sweat? 

Timing: How long does the back pain last for? Has it changed over time?  

Exacerbating/relieving factors: is it better with rest? 

Severity: where would you put the pain, 1-10. Ten being the worst? 

Now is a good idea to ask Ideas, Concerns & Expectations (ICE) 

Past medical history (PMH): 

Is there any chronic illness that I should know about that we have not covered? 

Allergies: 

Do you have any allergies I should know about? 

Drug history (DH):

Are you taking any medication to help with your back pain? If so, any side effects.

Have you tried any prescribed medications? If yes, has it helped? 

Family history (FMH): 

Is there any family history of osteo/rheumatoid arthritis I should know about? 

Social History (SH): 

Do you smoke? Any alcohol?  Any recent travel? Occupation? 

Possible differential diagnosis:

• Musculoskeletal (MSK):  acute onset, paraspinal muscle - not central 

• Lumbar arthritis: chronic back pain, back ache related to standing/ walking and sitting in one place, progressive stiffening 

• Lumbar disc-prolapse: pain while lifting, bending, sneezing, leg pain, weakness / numbness usually L4, L5/S1

• Thoracic pain: pancreatitis, aortic dissection, gastric, duodenal ulcer

• Paraspinal pain and unilateral flank pain: pyelonephritis or renal cell cancer.

• Sciatica: unilateral leg pain radiating below knee to the foot or toes. 

Red flag symptoms: 

• Cauda equina syndrome: incontinence, rented on, saddle anaesthesia, bilateral leg pain and weakness. 

• Spinal fracture: sudden onset of pain, better with lying down, might be after a trauma 

• Cancer: >50 yr, gradual onset back pain, pain constant, localised tenderness on palpation, lasting > 6 weeks, weight loss, past history of cancer. 

• Spinal infection: fever, recurrent UTI, background of diabetes, history of IV drug use, HIV/immunosuppressed. 

Investigation: 

• Bedside: neurological examination, Oxygen saturation (SPO2), pulse/heart rate (HR), blood pressure (BP), respiratory rate (RR), tympanic temperature

• Bloods : No specific blood test, but can check for inflammatory causes - c-reactive protein (CRP) + Erythrocyte Sedimentation Rate (ESR) 

• Imaging: Spinal XR 

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