The Case History

On Part III, the history is where the case is won or lost: the vignette hands you a few words from the patient, and the item asks what you should ask next, what the answer means and which diagnosis it makes likely. In the clinic the same skill decides whether a patient with back pain gets an adjustment, an x-ray or a same day trip to the emergency department. This chapter teaches you to turn a vague complaint into a focused, defensible history that has already narrowed the differential before you lay a hand on the patient.

Section 1The chief complaint and history of present illness

What the history is for

Studies in primary care have shown for decades that the history alone leads to the correct diagnosis in roughly 70 to 80 percent of patients; the physical examination and tests add comparatively little once a good history is in hand. For a chiropractor the history has three jobs. First, it sorts the patient into one of three diagnostic bins: serious pathology (about 1 to 2 percent of spinal pain patients), radicular syndrome (about 5 to 10 percent) and nonspecific mechanical pain (about 90 percent). Second, it generates a short list of hypotheses that the examination will test. Third, it establishes the baseline against which you will judge progress and on which your record stands if the case is ever reviewed.

The standard order is: identifying data, chief complaint (CC), history of present illness (HPI), past medical history (PMH), medications and allergies, family history (FH), personal and social history (SH), and the review of systems (ROS). Part III items test the logic inside each part: which question best discriminates between two diagnoses, which answer is a red flag, and which piece of history is missing.

The chief complaint

The chief complaint is recorded in the patient's own words, with its duration: "Low back pain going down my left leg for three weeks." It should not be a diagnosis ("sciatica" or "subluxation") because a premature label closes the mind. If a patient has several complaints, list them, ask which matters most, and take a separate HPI for each one, because a new symptom (for example, a headache in a patient who came for neck pain) may have a completely different cause.

OPQRST and OLDCARTS

Both mnemonics cover the same ground. OPQRST is Onset, Provocation and Palliation, Quality, Region and Radiation, Severity, and Timing. OLDCARTS is Onset, Location, Duration, Character, Aggravating factors, Relieving factors, Timing and Severity. What matters on the board is not the acronym but what each answer means.

Mechanism of injury

The mechanism is the history's best predictor of which tissue failed and whether a fracture is possible. Ask exactly what happened, the forces and their direction, the position of the body, what the patient felt and heard, and what they could do immediately afterward.

• Flexion with rotation under load (lifting a box and turning) concentrates stress on the posterolateral annulus: classic disc injury.
• Axial load (fall from height onto the feet or buttocks, diving into shallow water) produces compression or burst fractures, most often at the thoracolumbar junction (T11 to L2). A calcaneal fracture from a fall onto the heels travels with a lumbar fracture in about 10 percent of cases, so ask about heel pain and examine both.
• Repetitive hyperextension (gymnastics, football linemen, cricket bowlers, divers) stresses the pars interarticularis: spondylolysis in adolescents.
• Acceleration and deceleration in a motor vehicle collision causes whiplash associated disorders. Ask about direction of impact, whether the head was rotated (worse outcome), headrest height, seat belt and airbag, speed, awareness of the impending impact, and whether symptoms began immediately or the next day.
• Fall on an outstretched hand injures the scaphoid, distal radius, radial head and shoulder.
• Minimal trauma (a cough, stepping off a curb, lifting a grandchild) producing sharp thoracic or lumbar pain in an older or steroid treated patient is an osteoporotic compression fracture until proven otherwise.
• No mechanism at all is itself a finding: insidious pain without an event points away from simple strain and toward degenerative, inflammatory, neoplastic or infectious disease.

The timeline

Duration classifies spinal pain as acute (under 6 weeks), subacute (6 to 12 weeks) and chronic (over 12 weeks, or 3 months). The trajectory matters as much as the duration. Most acute mechanical episodes improve substantially within 2 to 6 weeks; a course that is steadily progressive despite rest and appropriate care is a red flag in itself. Ask about previous episodes, because a recurrent pattern of short mechanical episodes with full recovery between them is reassuring, while a first episode at age 55 or later deserves more caution. Ask what treatment has been tried and with what result: failure to improve after about four weeks of appropriate conservative care is a common trigger for imaging or referral.

Aggravating and relieving factors in more depth

The behavior of pain under load is one of the strongest clues to the pain generator. Flexion intolerance (worse with sitting, bending, lifting, driving, getting out of a chair, morning) fits a discogenic source, because flexion loads the anterior column and pushes nuclear material posteriorly. Extension intolerance (worse with standing, walking, lying prone, reaching overhead) fits the facet joints or stenosis, because extension loads the posterior elements and narrows the canal and foramina. Pain that is worse with cough, sneeze or straining (Valsalva) suggests a space occupying lesion that raises intrathecal pressure on a sensitized root, usually a disc herniation but occasionally a tumor. Pain relieved by sitting or flexing forward and brought on by walking, with leg symptoms, is the hallmark of neurogenic claudication from lumbar spinal stenosis, while leg pain on walking that eases with simply standing still suggests vascular claudication.

Worked examples: turning a vague complaint into a focused history

Section 2Past, family, personal and social history

Why the background history matters

The background history changes pretest probability. The same complaint of thoracic pain means one thing in a fit 25 year old rower and something very different in a 70 year old woman on long term prednisone or a 60 year old man treated for prostate cancer five years ago. Each element below should be asked with a purpose: to raise or lower the probability of a specific diagnosis, or to identify a contraindication to a specific treatment.

Past medical and surgical history

• Prior episodes of the same complaint, how they were treated and how they resolved. Recurrent mechanical episodes predict recurrence; previous good response to manipulation predicts a good response again.
• Prior injuries and fractures, including fragility fractures (wrist, hip, vertebra) that indicate osteoporosis.
• Prior spinal surgery (discectomy, laminectomy, fusion, disc replacement), with dates and levels. Fusion and instrumentation alter technique choice; failed back surgery syndrome changes prognosis; recent surgery with new fever or wound drainage suggests postoperative infection.
• Cancer, at any time. A history of cancer is the single strongest history predictor of malignancy as the cause of back pain (positive likelihood ratio roughly 15). The cancers that most often metastasize to bone are breast, prostate, lung, kidney and thyroid.
• Systemic disease: diabetes (neuropathy, infection risk, delayed healing), rheumatoid arthritis (atlantoaxial instability), inflammatory bowel disease and psoriasis (spondyloarthritis), osteoporosis, connective tissue disorders such as Ehlers Danlos and Marfan syndromes (hypermobility, arterial fragility), cardiovascular disease, kidney stones, and any immunosuppression (HIV, transplant, chemotherapy).
• Down syndrome: atlantoaxial instability in about 10 to 20 percent of patients.

Medications and allergies

Medications both reveal hidden diagnoses and change what you can safely do. Ask about prescription drugs, over the counter drugs, supplements and recreational drugs, and record allergies with the type of reaction.

Family history

Family history raises the probability of conditions with a genetic component. A first degree relative with ankylosing spondylitis or other spondyloarthritis, psoriasis or inflammatory bowel disease supports inflammatory back pain (HLA-B27). A family history of abdominal aortic aneurysm raises AAA risk several fold. Family history of premature cardiovascular disease (a male relative under 55 or a female relative under 65) matters in chest, jaw and arm pain. Ask also about cancer (breast, colon, prostate), osteoporosis and hip fracture in a parent (a FRAX risk factor), scoliosis (adolescent idiopathic scoliosis clusters in families), gout, rheumatoid arthritis, diabetes, migraine, connective tissue disorders and sudden cardiac death in a young relative (relevant to athletes).

Personal and social history

How each piece changes the working diagnosis

Think of each answer as a weight on a scale. Age over 50, prior cancer, unexplained weight loss and failure of a month of care push toward malignancy. Fever, injection drug use, recent infection (urinary tract, skin), immunosuppression, diabetes and recent spinal procedures push toward infection. Older age, osteoporosis, steroids and trauma push toward fracture. Age under 40, morning stiffness, alternating buttock pain, uveitis, psoriasis, inflammatory bowel disease and a family history of spondyloarthritis push toward axial spondyloarthritis. Smoking, hypertension, male sex, age over 60 and family history push toward AAA. A young, active, healthy patient with a clear mechanical onset sits firmly at the benign end.

Section 3Review of systems and red flag questioning

The systematic review of systems

The review of systems (ROS) is a structured head to toe inventory of symptoms the patient may not connect with the chief complaint. Its purpose in a chiropractic case is to find the patient whose musculoskeletal complaint is really systemic or visceral disease, and the patient who has a second problem that needs attention. A written intake questionnaire covers the ground efficiently; the clinician then asks follow up questions about every positive answer and about the systems most relevant to the complaint.

Red flag questions by category

Red flags are features of the history and examination that raise the probability of serious pathology. Individually most are weak; their value lies in combinations and in the strong ones. Know the question to ask for each threat and the urgency of referral if it is positive.

Cauda equina syndrome: the questions you must ask

Cauda equina syndrome results from compression of multiple lumbosacral roots below the conus medullaris, most often by a large central disc herniation at L4 to L5 or L5 to S1, less often by tumor, abscess, hematoma or severe stenosis. The single most sensitive finding is urinary retention (sensitivity about 90 percent); with retention, overflow incontinence follows. Ask every patient with back pain and leg symptoms, in plain words: "Have you had any trouble starting or stopping your urine, or any leaking?" "Any numbness between your legs or around your back passage, for example when you wipe after the toilet?" "Any change in bowel control?" "Any new problem with sexual function?" "Is the leg pain on both sides, or getting worse?" Document both positive and negative answers. Incomplete cauda equina syndrome (altered urinary sensation, reduced saddle sensation, retained control) carries a much better outcome after decompression than the retention stage, which is why the question must be asked early and the patient told to return immediately if any of these symptoms appear.

Vascular and visceral causes from the history

Visceral pain refers to the spine through shared segmental innervation, and its giveaway is that it does not behave mechanically: posture, movement and palpation do not reproduce it, while eating, urination, menstruation or exertion do. Kidney stones cause colicky flank pain radiating to the groin, with restlessness (the patient cannot get comfortable, in contrast to the stillness of mechanical pain) and hematuria. Pyelonephritis adds fever and dysuria. Pancreatitis gives boring epigastric pain through to the back, eased by leaning forward, often after alcohol or a fatty meal. Peptic ulcer on the posterior duodenal wall gives midthoracic pain related to meals. Gallbladder disease refers to the right scapula after fatty meals. Myocardial ischemia refers to the left arm, jaw, neck and interscapular region with exertion, sweating and dyspnea. Aortic dissection causes sudden tearing chest or interscapular pain. Gynecologic disease (endometriosis, ovarian cyst, ectopic pregnancy) causes low back and pelvic pain related to the menstrual cycle; in any woman of reproductive age with low abdominal or back pain, ask the date of the last menstrual period.

Cervical red flags and the vertebrobasilar screen

Before treating the neck, ask about the features of cervical artery dissection and vertebrobasilar insufficiency: recent onset of severe, unusual neck pain or occipital headache (often described as different from any previous headache), especially after minor trauma, sport or prolonged neck extension; and the brainstem symptoms summarized as the 5 Ds and 3 Ns: dizziness, diplopia, dysarthria, dysphagia, drop attacks, ataxia of gait, nausea, nystagmus and numbness (often facial or perioral). Internal carotid dissection may produce an ipsilateral Horner syndrome (ptosis, miosis, anhidrosis) and pulsatile tinnitus. A thunderclap headache (maximal within a minute) suggests subarachnoid hemorrhage. Also ask about features of upper cervical instability: rheumatoid arthritis, Down syndrome, recent trauma, a sense that the head is heavy or unstable, and bilateral paresthesias.

Yellow flags: predicting chronicity

Yellow flags are psychosocial factors that predict persistent pain and disability rather than serious disease. They include fear avoidance beliefs (the belief that movement or work will cause harm), catastrophizing, low mood and depression, anxiety, passive coping (waiting to be fixed), poor sleep, social withdrawal, job dissatisfaction and conflict at work, compensation and litigation issues, and a history of long time off work. Related color flags include blue flags (the worker's perception of the workplace) and black flags (system or contextual barriers such as employer policy or the compensation system). Orange flags denote psychiatric disorders such as major depression or personality disorder that require referral.

Section 4Building differential diagnoses from the history

From pattern recognition to probability

Experienced clinicians reason in two modes. Pattern recognition (fast, intuitive) matches the story to an illness script stored from experience: "young man, lift and twist, leg pain below the knee worse with sitting: disc." Analytical reasoning (slow, deliberate) lists possibilities systematically and weighs evidence for each. Pattern recognition is efficient but vulnerable to cognitive biases; analytic reasoning is the check on it. Good practice is to form an early hypothesis from the pattern and then deliberately ask, "What else could this be, and what must I not miss?"

Pretest probability is the probability of a diagnosis before a test is performed, and it comes chiefly from prevalence in the setting and from the history. A test result moves probability, and the size of that move is captured by the likelihood ratio (LR). A positive LR above 10 or a negative LR below 0.1 produces a large, often decisive shift; LRs of 2 to 5 (or 0.2 to 0.5) produce small but sometimes important shifts; an LR near 1 changes nothing. Every history question is a test in this sense. A history of cancer in a back pain patient carries a positive LR near 15; age over 50 alone carries a positive LR near 2.7; "pain not relieved by bed rest" has an LR barely above 1. A highly sensitive finding, when absent, helps rule a condition out (SnNout); a highly specific finding, when present, helps rule it in (SpPin).

Mechanical versus nonmechanical pain

The first branch point in any spinal differential is whether the pain is mechanical. Mechanical pain changes with posture, movement and load, has a position of relief, can be reproduced on examination, and usually follows a recognizable onset. Morning stiffness is brief (under 30 minutes). Nonmechanical pain is constant or progressive, does not change with position, is often worse at night, and is accompanied by systemic or organ specific symptoms. Nonmechanical pain has three broad sources: systemic disease (tumor, infection, inflammatory arthritis, metabolic bone disease), visceral referral and neuropathic or central pain. A mixed picture is common, for example a mechanical overlay on a metastatic lesion, so a mechanical component never excludes serious disease when red flags are present.

Radicular, referred and central patterns

Separating the distribution of pain is the second branch point. Somatic referred pain arises from a spinal structure (facet joint, disc, sacroiliac joint, muscle) and is felt as a deep, diffuse, poorly localized ache in the same segmental territory, usually not below the knee in the lower limb or below the elbow in the upper. Radicular pain arises from an irritated nerve root and is sharp, shooting or burning, felt in a narrow band, often extends below the knee into the foot, and is usually worse in the limb than in the back. Radiculopathy is the objective loss of root function (dermatomal sensory loss, myotomal weakness, reduced reflex). Myelopathy is cord compression with bilateral symptoms, clumsy hands, gait disturbance and upper motor neuron signs. Visceral referred pain follows the dermatomes of the organ's sympathetic afferents (heart to T1 to T4 and the left arm; gallbladder to the right scapula; kidney to the flank and groin; pancreas to the upper lumbar region). Nociplastic pain (central sensitization) is widespread, disproportionate, with allodynia and hyperalgesia.

Avoiding cognitive traps

• Anchoring: locking onto the first impression (the patient said "I pulled something") and discounting later contradicting facts (weight loss, night pain).
• Premature closure: stopping the search once one plausible diagnosis is found. A disc herniation and a prostate cancer metastasis can coexist.
• Availability bias: overweighting diagnoses seen recently or vividly.
• Confirmation bias: asking only questions that support the favored hypothesis. Deliberately ask a question that would disprove it.

Section 5Communication, special populations and documentation of the history

Asking questions well

Begin with open ended questions ("Tell me about the pain," "What brings you in today?") and allow the patient to speak without interruption for the first minute or two; most patients finish their opening statement in under two minutes, and interrupting early loses information. Then narrow with focused questions ("Where exactly does it go?") and finish with closed questions that confirm or exclude specific features ("Any numbness between your legs?"). Avoid leading questions ("The pain doesn't go down your leg, does it?") and compound questions that ask two things at once. Use facilitation (nodding, "go on"), clarification ("What do you mean by dizzy: is the room spinning, or do you feel faint?"), reflection and summarizing ("Let me check I have this right...") to confirm accuracy. End by asking, "Is there anything else you think I should know?" and "What are you most worried this might be?" The second question often reveals a fear (cancer, paralysis, losing a job) that shapes the patient's recovery.

Clarifying vague terms

Patients use words that mean different things to different people. Dizziness may be vertigo (a spinning illusion, vestibular or brainstem), presyncope (near fainting, cardiovascular or orthostatic), disequilibrium (unsteadiness on the feet, neurologic or proprioceptive) or vague lightheadedness (often anxiety or medication). Numbness may mean loss of sensation, tingling or a feeling of heaviness. Weakness may mean true loss of strength, fatigue or pain inhibition.

Special populations

Interpreters

Family members, and especially children, should not interpret a clinical history except in an emergency: they may filter or omit sensitive information (bladder, sexual or abuse history), lack medical vocabulary and compromise confidentiality. A trained medical interpreter translates exactly and keeps confidentiality. Speak in the first person directly to the patient, and document the language and the interpreter's name or ID, using the same approach for informed consent.

The pregnant patient

Low back and pelvic girdle pain affect more than half of pregnant women, and most is mechanical, related to relaxin mediated ligamentous laxity, weight gain, an anterior shift of the center of gravity and increased lumbar lordosis. The history must still screen for obstetric emergencies. Rhythmic low back pain that comes and goes with tightening of the abdomen may be preterm labor. Vaginal bleeding with constant abdominal or back pain and a rigid uterus suggests placental abruption. Headache, visual disturbance, right upper quadrant or epigastric pain and sudden swelling after 20 weeks suggest preeclampsia; check blood pressure. Fever with flank pain suggests pyelonephritis, which is more common in pregnancy. Unilateral calf pain and swelling suggests DVT, whose risk is several times higher in pregnancy and the postpartum period. In the first trimester, unilateral pelvic pain with spotting raises ectopic pregnancy.

Documenting the history in a defensible record

The record is a clinical, legal and billing document. It must allow another clinician to understand what you found, what you thought and why you did what you did. A defensible history has these features:

• Legible, dated and signed (or authenticated in the electronic record), written at the time of the visit or promptly after.
• Chief complaint in the patient's words with duration; HPI with each OPQRST element; mechanism of injury with specific details (for a collision: direction, speed estimate, seat belt, head position, onset of symptoms).
• Pertinent negatives: "Denies saddle anesthesia, bladder or bowel dysfunction, fever, weight loss, night pain." If it is not written, a reviewer will assume it was not asked.
• Baseline functional status and outcome measures (pain scale, Oswestry or Neck Disability Index, activities the patient cannot do) and the patient's goals, which justify the plan and later demonstrate medical necessity.
• Medications and allergies and relevant comorbidities that modify care.
• Objective, nonjudgmental language: record what the patient said in quotation marks rather than labels such as "malingerer" or "drug seeker."
• Corrections made by a single line through the original entry with the date, time and initials, never by obliterating or rewriting; late entries labeled as such with the current date. Altering a record after a complaint or claim is one of the most damaging things a clinician can do.
• Communication with others (phone calls, referrals, advice to go to the emergency department, refusals) with time and content.

Words worth knowing