THESE ARE THE SALIENT POINTS TO BE ELICITED IN HISTORY TAKING FOR SPINE CASE.
HISTORY:
CHIEF COMPLAINTS:
1. BACKPAIN:
onset, duration ,progress
site, radiation, character, agg. and relieving factors, severity
mechanical/non-machanical
2. LEG PAIN:
referred / radicular / claudicant
uni / bilateral
exact dermatomal distribution / glove and stocking
pareasthesiae / numbness
agg. and rel. factors
3. WEAKNESS:
onset, duration, progress
location, symmetry, UL /LL
progressive / fluctuating / exercise-induced
4. SPHINCTER DISTURABANCES:
urinary frequency /incontinence /retention
incontinence of faeces / perineal numbness
5.DEFORMITY:
onset / progress / severity
chest / waist / shoulder-blade
sense of going off-balance
loss of height
cosmetic effect and psychological effects
PAST HISTORY:
similar episodes, treatmet taken
past surgeries and post-op. follow-up
conservative modalities tried
ETIOLOGICAL HISTORY:
Trauma: duration, mechanism, severity, effects, treatment
taken, surgeries, cons. modalities
Tuberculosis: h/o fever, cough, wt. loss
Medical illness
Primary malignancy
Age: osteoporosis, sec. malignancy
Associated cong. anomalies
MEDICAL HISTORY:
visceral back pain
ass. illness mimicking spinal pain
for fitness for surgery
peri-op. control
SOCIAL HISTORY:
type of work, compensation illness
smoking/ alcohol
FAMILY HISTORY:
idiopathic scoliosis and other syndromes
CURRENT FUCNTIONAL STATUS:
household / community ambulator
walking aids / bedridden
employed? compensation claims
extent of restriction of walking
improvement after cons. Rx
NOW FRAME D/D FROM HISTORY
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