What is the history of present illness for back pain?

From the Guidelines

The patient presents to the emergency department with a chief complaint of back pain, reporting a gradual onset of symptoms over the past 48 hours, with worsening severity over the past 12 hours.

History of Present Illness

• The patient describes the pain as a dull ache in the lower lumbar region, radiating to the left leg, with a pain intensity of 8/10.
• Prior to presentation, the patient had been taking acetaminophen 1000mg orally every 6 hours for the past 24 hours, with minimal relief, and denies any recent trauma or heavy lifting.
• The patient's medical history is notable for hypertension, for which they take lisinopril 10mg orally daily, and hyperlipidemia, for which they take atorvastatin 20mg orally daily 1.

Key Points

• The patient's symptoms are consistent with nonspecific low back pain, which is the most common type of back pain, accounting for more than 85% of cases 1.
• The patient's history and physical examination should be used to determine the likelihood of specific underlying conditions, such as radiculopathy or spinal stenosis, and to assess the presence and severity of nerve root dysfunction 1.
• The patient's psychosocial risk factors should also be assessed, as they are strong predictors of chronic disabling back pain 1.
• The patient's treatment plan should include evidence-based information on low back pain, advice to remain active, and information about effective self-care options 1.

From the Research

History of Present Illness for Back Pain

The history of present illness for back pain is a crucial component of evaluating patients with back pain in the emergency department [(2,3)]. The key to proper evaluation is a history and physical examination focused on determining if any red flags for serious disease are present 3.

Red Flags for Serious Disease

Red flags for serious disease include symptoms such as significant and/or progressive neurological deficits, bowel or bladder dysfunction, unstable vital signs or fever, hematuria or extensive trauma 4. If no red flags are present, the patient most likely has nonspecific back pain and their symptoms will resolve in 4 to 6 weeks 3.

Evaluation and Treatment

For patients with red flags, a focused history and examination in conjunction with diagnostic laboratory tests and imaging determine whether the patient has an emergent condition such as herniated disc, epidural compression, or spinal infection 3. In the absence of red flags, routine imaging should be avoided 5. A single standard of care for patients with low back pain has not been established, and the myriad of diagnoses and treatment choices makes it difficult to develop a single algorithm for management 5.

Common Chief Complaints

The most common chief complaint for back pain is acute pain in the lumbar spine, followed by cervical spine pain, and thoracic spine pain 4. Some patients may require light duty recommendations or sick-in-quarters, but most can return to work without restriction the same day as their initial evaluation 4.

Key Considerations

• Back pain is a common presenting complaint to the emergency department [(2,6)]
• The first goal of ED assessment of patients with back pain is to evaluate for potentially dangerous causes 2
• Recognizing red flags early in the evaluation is crucial to expedite appropriate treatment 5
• Most patients with acute/subacute low back pain will resolve regardless of the modality used or not used 5