Katy Perry

56 yearsold
OSCE Checklist: Back Pain History Taking
Opening the consultation
1 Wash your hands and don PPE if appropriate

2 Introduce yourself to the patient including your name and role

3 Confirm the patient's name and date of birth

4 Explain that you'd like to take a history from the patient

5 Gain consent to proceed with taking a history

Presenting complaint
6 Use open questioning to explore the patient’s presenting complaint

History of presenting complaint

7 Site: ask about the location of the back pain pointtopain
8 Onset: clarify when the back pain first started and if it the onset was sudden or gradual
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9 Character: ask about the specific characteristics of the back pain
pigggetatres
constant
10 Radiation: ask if the back pain moves anywhere else

11 Associated symptoms: ask if there are any other associated symptoms

12 Time course: ask how the back pain has changed over time straining bingddfetnithelp

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13 Exacerbating or relieving factors: ask if anything makes the back pain worse
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or better doesn't

14 Severity: ask how severe the back pain is on a scale of 0-10 motu sensory That
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15 Screen for other key symptoms including red flag features hematuria
16 Explore the patient's ideas, concerns and expectations

17 Summarise the patient’s presenting complaint

MEI weightloss
musclespasms

Systemic enquiry
18 Screen for relevant symptoms in other body systems

Past medical and surgical history

19 Ask if the patient has any medical conditions including previous back problems
thyroidcancer
20 Ask if the patient has undergone any relevant surgical procedures
thywidectomy
21 Ask if the patient has any allergies and if so, clarify what kind of reaction they had to the
substance
x
Drug history
22 Ask if the patient is currently taking any prescribed medications or over-the-
counter remedies
levothyroxine paracetamol

REDFLAGS T U N A F I S H
MNEMONIC fever Steroids
Migns 750 hygof
unexplained Ndrugs
trauma
weightles
Family history
23 Ask the patient if there is any family history of back problems, inflammatory arthritis,
malignancy or cardiovascular disease

Social history
24 Explore the patient’s general social context

25 Take a smoking history

26 Take an alcohol history

27 Ask about recreational drug use

28 Gather details about the patient’s occupation

29 Ask about any hobbies which may be relevant to their back pain

Closing the consultation

30 Summarise the salient points of the history back to the patient and ask if they feel anything
has been missed
31 Thank the patient for their time

32 Dispose of PPE appropriately and wash your hands

Key communication skills

33 Active listening

34 Summarising

35 Signposting

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Q
investigations

FBC anemia
ESR Differentials
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AAA
Utes Fracture
Boneprofile
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FTS ALP T with bony nets
Paget's
Nerverootpain
Imaging
cauda equira
MRI of thewholespine osteoarthritis