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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 standing/walking a lot/sitting in one place

  • Progressive stiffening

Lumbar disc prolapse

  • Acute onset while lifting / bending / sneezing / coughing

  • Severe pain

  • Sciatica, leg pain often worse than back pain

  • 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

    • Paget’s disease

    • Spondylolisthesis

    • Osteoporotic vertebral collapse

  • Abdominal

    • Pyelonephritis

    • PID

    • 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

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What are the RED FLAGS of back pain?

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What treatment options are there for chronic nonspecific back pain?

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

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Name the three main causes of spinal disc pathology

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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…

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Common presenting complaints