🏥 Stations

🧠 Qbank

🫀 Conditions

📖 Book

😃 More

💳 Pricing

🔒 Dashboard

📖 OSCE Learning

🔒 OSCE Stations

🔒 Qbank

🔐 Membership
Share your insights

Help us by sharing what content you've recieved in your exams


Common orthopaedic and rheumatological histories

History taking > Common presenting complaints

Lower back pain

Exploring symptom

  • Pain
    • Site
    • Onset
    • Character
    • Radiation
    • Associated symptoms
    • Timing
    • Exacerbating/relieving factors
    • Severity
  • Associations
    • Sciatica, stiffness/deformity, incontinence, neurological symptoms
  • Red flags
    • Cauda equina: urinary incontinence/retention, faecal incontinence/constipation, bilateral leg pain, severe/progressive neurological deficit, saddle anaesthesia, sexual dysfunction
    • Infection or cancer: age <20 or >55 years at onset, cancer Hx, night pain, weight loss, fever, night sweats, injecting drugs, immunosuppression
    • Fracture: trauma, severe central spinal pain
    • Spondyloarthropathy: early morning stiffness, worse with rest

Relevant system reviews

  • General
    • Fever, night sweats, weight loss
  • Neuro (lower limbs)
    • Motor: weakness/wasting, incontinence 
    • Sensory: pain, numbness, tingling

Differential diagnoses and clues

Orthopaedic

Muscular

  • Acute onset lower back pain

  • Paraspinal muscles affected, not central

Lumbar spondylosis

Includes lumbar facet joint syndrome (lumbar arthritis)

    • Chronic episodic mechanical lower back pain

    • Backache related to position/exertion

    • Progressive stiffening

Lumbar disc prolapse

    • Acute onset while lifting / bending / sneezing / coughing

    • Severe pain

    • Sciatica

    • Neurological symptoms, e.g. weakness, numbness (usually L4/L5/S1 distribution)

Discitis

  • Fever and systemic upset

  • Risk factors, e.g. injecting drug user

Spinal fracture

  • History of trauma

  • Sudden onset

Cauda equina syndrome

  • Urinary incontinence/retention

  • Faecal incontinence/constipation

  • Saddle anaesthesia or paraesthesia

  • Bilateral leg pain and weakness

Rheumatological

Ankylosing spondylitis

  • Morning stiffness >30 minutes

  • Pain worse on rest

Others

Others

    • Bony

        • Myeloma bone lesions

        • Bony metastasis

        • Osteoporotic vertebral collapse

    • Abdominal

        • Pyelonephritis

        • Pancreatitis

        • AAA

Joint pain / stiffness / swelling

Exploring symptom

  • Pain
    • Site(s)
    • Onset
    • Character
    • Radiation
    • Associated symptoms
    • Timing
    • Exacerbating/relieving factors
    • Severity
  • Stiffness/swelling
    • Worse in morning?, how long for (>30 mins = inflammatory; <30 mins = osteoarthritis)
    • Better or worse after exercise
    • Sleep disturbance
    • Loss of function

Relevant system reviews

  • General
    • Fever, rashes, weight loss
  • Rheumatological
    • Joints: pain, stiffness, swelling
    • Work down body: skin (rashes, ulcers, Raynaud’s), hair loss, eyes (redness, dryness), mouth (dryness), chest (breathlessness, SOB), GI (IBD symptoms), genitourinary (discharge

Differential diagnoses and clues

Rheumatological

Rheumatoid arthritis

  • Slowly progressive symmetrical polyarthropathy

  • Small joints (commonly of hand)

  • Deforming

  • Early morning stiffness

Gout

  • First MTP joint most commonly affected

  • Isolated swollen, hot, painful joint

  • Hyperuricaemia risk factors, e.g. diuretics, alcohol excess (esp. beer), renal disease

Psoriatic arthritis

  • Associated skin plaques and nail changes

  • Early morning stiffness

  • Many patterns of joint involvement

SLE

  • Systemic illness with intermittent fevers

  • Photosensitive rash

  • Generalised myalgia and arthralgia

  • Other systemic symptoms (e.g. psychiatric, pleurisy, ulcers)

Enteropathic arthritis

  • Symmetrical arthritis of lower limb joints and sacroiliac joints

  • Early morning stiffness

  • Symptoms/diagnosis of Crohn’s or UC

Orthopaedic

Osteoarthritis

  • Elderly

  • Worse on movement (rest helps) and at end of day, night pain common

Septic arthritis

  • Isolated hot, red, swollen joint

  • Agonizingly painful

  • Systemically unwell with fever

Others

Others

Single joint

  • Traumatic (dislocation/fracture/ligament injury)
  • Haemarthrosis (Haemophilia or traumatic)
  • Pseudogout
  • Adhesive capsulitis
  • Transient synovitis
  • Bursitis
  • Reactive arthritis
  • Joint specific problems

Multiple joints

  • Viral infections (e.g. parvovirus B19)
  • Disseminated bacterial infections (e.g. Staphylococcus aureus)
  • Ankylosing spondylitis
  • Reactive arthritis
  • Juvenile chronic arthritis
  • Rheumatic fever

Try some viva questions

Please list some differentials for lower back pain

Oops! This section is restricted to members. Click here to signup!

What are the RED FLAGS of back pain?

Oops! This section is restricted to members. Click here to signup!

What treatment options are there for chronic nonspecific back pain?

Oops! This section is restricted to members. Click here to signup!

Which investigations may be used to help differentiate the causes of back pain?

Oops! This section is restricted to members. Click here to signup!

Name the three main causes of spinal disc pathology

Oops! This section is restricted to members. Click here to signup!

Now it’s your turn to shine! Here are some history stations…

  1. Back pain
  2. Joint pain
  3. And more joint pain!
  4. Time for a different joint
  5. See more here…

No comments yet 😉

Leave a Reply

Common presenting complaints