4 The History and Clinical Examination
The Massachusetts General Hospital Handbook of Pain Management
The History and Clinical Examination
Jan Slezak and Asteghik Hacobian
To each his suff’rings: all are men,
Condemn’d alike to groan,
The tender for another’s pain,
Th’ unfeeling for his own.
—Thomas Gray, 1716–1771
I. Patient interview
1. Pain history
2. Medical history
3. Drug history
4. Social history
II. Patient examination
1. General examination
2. Systems examination
III. Inconsistencies in the history and physical examination
The key to accurate diagnosis is a comprehensive history and detailed physical examination. Combined with a review of the patient’s previous records and diagnostic studies, these lead to a diagnosis and appropriate treatment. In pain medicine, a majority of patients have seen multiple providers, have had various diagnostic tests and unsuccessful treatments, and are finally referred to the pain clinic as a last resort. With advances in research and better education of primary care providers, this trend is beginning to change, and more patients are being referred to pain management specialists earlier, with better outcomes as a result.
I. PATIENT INTERVIEW
1. Pain history
Development and timing
The pain history should reveal the location of the pain, the time of its onset, its intensity, its character, associated symptoms, and factors aggravating and relieving the pain.
It is important to know when and how the pain started. The pain onset should be described and recorded (e.g., sudden, gradual, rapid). If the pain started gradually, patients find identifying an exact time of onset difficult. In the case of a clear inciting event, the date and circumstances of onset of pain may point to the event. The condition of the patient at the onset of pain should be noted if possible. In cases of motor vehicle accidents or work-related injuries, the state of the patient before and at the time of the impact should be clearly understood and documented.
The time of the onset of the pain can be very important. If that interval is short, as in acute pain, the treatment should focus on the underlying cause. In chronic pain, the underlying cause has usually resolved and the treatment should focus on chronic pain management.
Various methods are used to measure the intensity of pain, fully described in Chapter 6. Because the complaint of pain is purely subjective, it can be compared only to the sufferer’s own pain over a period of time; it cannot be compared to another person’s report of pain. Of the numerous scales for reporting the so-called level of pain, the most common is the visual analog scale (VAS) of pain intensity, in which patients are instructed to place a marker on a 100-mm continuous line between “no pain” and “worst imaginable pain.” The mark is measured using a standard ruler and recorded as a numeric value between 0 and 100.
An alternative method of reporting the intensity of pain is the numeric rating scale. The patient directly assigns a number between 0 (no pain) and 10 (the worst pain imaginable). Another commonly used method is a verbal categorical scale, with intensity ranging from no pain through mild, moderate, and severe to the worst possible pain.
The patient’s description of the character of pain is quite helpful in distinguishing between different types of pain. For example, burning or “electric shocks” often describe neuropathic pain, whereas cramping usually represents nociceptive visceral pain (spasm, stenosis, or obstruction). Pain described as throbbing or pounding suggests vascular involvement.
The pattern of pain-spread from the onset should also be noted. Some types of pain change location or spread further out from the original area of insult or injury. The direction of the spread also provides important clues to the diagnosis and ultimately to the treatment of the condition. For example, a complex regional pain syndrome can start in a limited area, such as a distal extremity, and then spread proximally, in some instances even to the contralateral side.
The examiner should ask about the presence of associated symptoms, including numbness, weakness, bowel and or bladder dysfunction, edema, cold sensation, or loss of use of an extremity because of pain.
Aggravating and relieving factors
Aggravating factors should be elicited, because they sometimes explain the pathophysiologic mechanisms of pain. Various stimuli can exacerbate pain. Exacerbating mechanical factors, such as different positions or activities (sitting, standing, walking, bending, and lifting) may help differentiate one cause of pain from another. Biochemical changes (e.g., glucose and electrolyte levels, hormonal imbalance), psychological factors (e.g., depression, stress, and other emotional problems), and environmental triggers (e.g., dietary influences, weather changes including barometric pressure changes) may surface as important diagnostic clues.
Relieving factors are also important. Certain positions will alleviate pain better than others (e.g., in most cases of neurogenic claudication, sitting is a relieving factor, whereas standing or walking worsens the pain). Pharmacologic therapies and “nerve blocks” affording relief to the patient help the clinician determine the diagnosis and select the appropriate treatment.
All previously attempted treatment modalities should be listed at the interview. Knowing the history of the degree of pain relief, the duration of treatment, the dosages of prior medications, and adverse reactions helps to avoid repeating procedures or using pharmacologic management that has not helped in the past. The list should include all treatment modalities including physical therapy, occupational therapy, chiropractic manipulation, acupuncture, psychological help, and visits to other pain clinics.
2. Medical history
Review of systems
A complete review of all systems is an integral part of a comprehensive evaluation for chronic and acute pain. Some systems could be directly or indirectly related to the patient’s presenting symptoms and some are important in the management or treatment of the painful condition. Examples are the patient with a history of bleeding problems who may not be a suitable candidate for certain injection therapies, and someone with impaired renal or hepatic function who may need adjustments in medication dosage.
Past medical history
All medical problems that the patient has had in the past should be reviewed, including conditions that were resolved. Previous trauma and any psychological or behavioral issues in the past or present should be recorded.
Past surgical history
A list of all operations and complications should be made, preferably in chronological order. As some painful chronic conditions are sequelae of surgical procedures, this information is important for diagnosis and management.
3. Drug history
The practitioner must prescribe and intervene based on the knowledge of which medications the patient is taking, because complications, interactions, and side effects need to be taken into account. A list should be made of all medications currently being used by the patient, including pain medications. It should also include nonprescription and alternative medications (e.g., acetaminophen, aspirin, ibuprofen, and vitamins).
Allergies, both to medications and to nonmedications (latex, food, environmental), should be noted. The nature of a specific allergic reaction to each medication or agent should be clearly documented.
4. Social history
General social history
Understanding the patient’s social structure, support systems, and motivation is essential in analyzing psychosocial factors. Whether a patient is married, has children, and has a job makes a difference. Level of education, job satisfaction, and general attitude towards life are extremely important. Smoking, alcohol consumption, and history of drug or alcohol abuse are important in evaluating and designing treatment strategies. Lifestyle questions about how much time is taken for vacation or is spent in front of television, favorite recreations and hobbies, adequate exercise, and regular sleep, give the practitioner a more comprehensive overview of the patient.
A complete family history, including health status of the patient’s parents, siblings, and offspring, offers important clues for understanding a patient’s biologic and genetic profile. The existence of any unusual diseases in the family should be noted. A history of chronic pain and disability in family members (including the spouse) should be ascertained. Even clues that have no direct genetic or biologic basis may help by revealing coping mechanisms and codependent behavior.
The patient’s highest level of education completed and degrees obtained should be identified. The specifics of the present job and as well as of previous employment should be noted. The amount of time spent on each job, reasons for leaving, any previous history of litigation, job satisfaction, whether the patient works full time or part time are important in establishing the occupational framework. Whether the patient has undergone disability evaluations, functional capacity assessment, or vocational rehabilitation is also relevant.
II. PATIENT EXAMINATION
The clinical examination is a fundamental and valuable diagnostic tool. Over the past few decades, advances in medicine and technology and a better understanding of the pathophysiology of pain have dramatically improved the evaluation process. The lack of a specific diagnosis in a majority of patients presenting to the pain clinic underscores the need for detail-oriented examinations.
The consequences of improper coding and inadequate documentation to support charges billed to Medicare for evaluation and management services include various sanctions. Complying with regulations by appropriate documentation not only will result in higher reimbursement but also will provide protection against fraud and abuse. The number of levels of evaluation and management services that can be coded depends on the complexity of the examination, which in turn reflects the nature of the presenting problem and the clinical judgment of the provider. Types of examinations include either general multisystem (10 organ systems: musculoskeletal, nervous, cardiovascular, respiratory, ear/nose/mouth/throat, eyes, genitourinary, hematologic/lymphatic/ immune, psychiatric, and integumentary) or single-organ-system examinations. In pain medicine, the most commonly examined systems are the musculoskeletal and nervous systems.
If interventional pain management is part of a diagnostic or therapeutic plan, the evaluation should reveal whether the patient has risk factors for the procedure being considered. Coagulopathy, untreated infection, or preexisting neurologic dysfunction should be documented prior to placement of a needle or catheter or implantation of a device. Extra caution is needed when administering medications such as (a) local anesthetics to a patient with seizure disorder, (b) neuraxial anesthetics to a patient who may tolerate vasodilatation poorly, or (c) glucocorticoids to a diabetic patient. Preanesthetic evaluation should assess ability to tolerate sedation or the anesthesia itself if indicated for a procedure.
The following sections outline a physical examination that incorporates the musculoskeletal and neurologic assessment relevant to pain practice. The examination starts with the evaluation of single systems and commonly proceeds from head to toe.
1. General examination
(i) Constitutional Factors
Height, weight, and vital signs (blood pressure, heart rate, respiratory rate, body temperature) should be measured and recorded. Appearance, development, deformities, nutrition, and grooming are noted. Scan the room for presence of assistive devices brought by the patient. Patients who smoke or drink heavily may carry an odor. Observing the patient who is unaware of being watched may reveal discrepancies that were not seen during the evaluation.
(ii) Pain behavior
Note facial expression, color, and grimacing. Speech patterns suggest emotional factors as well as intoxication with alcohol or prescription or nonprescription drugs. Some patients attempt to convince the practitioner how much pain they are suffering by augmenting their verbal presentation with grunting, moaning, twitching, grabbing the painful area, exaggerating the antalgic gait or posture, or tightening muscle groups. This, unfortunately, makes the objective examination more difficult.
Evaluate for color, temperature, rash, and soft-tissue edema. Trophic changes of skin, nails, and hair are frequently seen in advanced stages of complex regional pain syndrome.
2. Systems examination
(i) Cardiovascular System
A systolic murmur with propagation suggests aortic stenosis, and the patient may not tolerate the hypovolemia and tachycardia that accompany rapid vasodilatation (e.g., after administration of neuraxial local anesthetics or sympathetic or celiac plexus blockade). The patient with irregular rhythm may have atrial fibrillation and be anticoagulated. Feel the pulsation of arteries (diabetes, complex regional pain syndrome, thoracic outlet syndrome), venous filling, presence of varicosities, and capillary return.
Examination of lungs may reveal abnormal breath sounds such as crackles, which may be a sign of congestive heart failure and low cardiac reserve. Rhonchi and wheezes are signs of chronic obstructive pulmonary disease. Caution in performing blocks around the chest cavity is advised, as there is an increased risk of causing pneumothorax.
(iii) Musculoskeletal system
The musculoskeletal system examination includes inspection of gait and posture. Deformities and deviation from symmetry are observed. After taking the history, the examiner usually has an idea from which body part the symptoms originate. If this is not the case, a brief survey of structures in the relevant region might be necessary. Positive tests then warrant further and more rigorous evaluation of the affected segment.
Palpation of soft tissues, bony structures, and stationary or moving joints may reveal temperature differences, presence of edema, fluid collections, gaps, crepitus, clicks, or tenderness. Functional comparison of the left and right sides, checking for normal curvature of the spine, and provocation of usual symptoms with maneuvers can help identify the mechanisms and location of the pathologic process.
Examination of range of motion may demonstrate hyper- or hypomobility of the joint. Testing active movement will determine range, muscle strength and willingness of the patient to cooperate. Passive movements, on the other hand, when performed properly, test for pain, range, and end-feel. Most difficulties arise when examining patients in constant pain, as they tend to respond to most maneuvers positively, therefore making the specificity of tests low.
For the patient with back pain, the suggested sequence of examinations is testing of range of motion of cervical, thoracic, and lumbosacral spine; sacroiliac and hip joints; and the straight leg raising test (see Chapter 27).
Straight leg raising test
The straight leg raising (or Lasegue’s Sign) test determines the mobility of the dura and dural sleeves from L4 to S2. The sensitivity of this test to diagnose lumbar disc herniation ranges between .6 and .97, with a specificity of .1 to .6. Tension on the sciatic nerve begins with 15 to 30 degrees of elevation in the supine position. This puts traction on the nerve roots from L4 to S2 and on the dura. The end of the range is normally restricted by hamstring muscle tension at 60 to 120 degrees. More than 60 degrees of elevation causes movement in the sacroiliac joint and therefore may be painful in sacroiliac joint disorders.
Basic sacroiliac tests
Sacroiliac tests are performed to determine when pain occurs in the buttock.
Push the ilia outward and downward in the supine position with the examiner’s arms crossed. If gluteal pain results, the test is repeated with patient’s forearm placed under the lumbar spine to stabilize the lumbar joints.
Forcibly compress the ilia to the midline with the patient lying on the painless side. This stretches posterior sacroiliac ligaments.
Exert forward pressure on the center of the sacrum with the patient prone.
Patrick’s or “FABER’S” test—Flex, abduct, and externally rotate femur while holding down contralateral anterior superior iliac spine. Stretches anterior sacroiliac ligament and reveals pain caused by ligamentous strain.
Force lateral rotation of the hip joint with knee held in 90 degrees of flexion and the patient in the supine position.
Spinal flexion, extension, and rotation and lateral bending may be limited or painful, leading to a diagnosis of zygapophyseal joint, discogenic, muscular, or ligamentous pain.
Adson’s test has been advocated for diagnosis of thoracic outlet syndrome. The examiner evaluates the change of radial artery pulsation in a standing patient with arms resting at the side. Ipsilateral head rotation during inspiration may cause vascular compression by the anterior scalene muscle. During the modified Adson’s test, the patient’s head is rotated to the contralateral side. Pulse change suggests compression by the middle scalene muscle. Both tests are regarded by some as unreliable, as the findings may be found positive in about 50% of the normal population.
The Tinel test involves percussion of the carpal tunnel. When it is positive, it gives rise to distal paresthesias. It can be performed at other locations (e.g., the cubital or tarsal tunnel), where it might be suggestive of nerve entrapment. Phalen’s test is positive for carpal tunnel syndrome when a passive flexion in the wrist for 1 minute, followed by sudden extension, results in sensation of paresthesias.
(iv) Neurologic examination
Table 1 summarizes the localization of cervical and lumbar radicular nerves.
Table 1. Cervical and lumbar radicular localization
Evaluation of the motor system starts with observation of muscle bulk and tone and the presence of spasm. Muscle strength is tested in upper and lower extremities. Weakness might be caused by the patient’s unwillingness to cooperate or trying to prevent pain provocation, or by poor effort, reflex neural inhibition in the painful limb, or an organic lesion. Further information is obtained by examination of deep tendon reflexes, clonus, and pathologic reflexes such as the Babinski. Evaluation of coordination and fine motor skills may reveal associated dysfunctions.
The integrity of cranial nerve function is tested by examination of visual fields, pupil and eye movement, facial sensation, facial symmetry and strength, hearing (using tuning fork, whisper voice, or finger-rub), spontaneous and reflex palate movement, and tongue protrusion.
Sensation is tested to light touch (A-b fibers), pinprick (A-D fibers), hot and cold stimuli (A-D and C fibers). Tactile sensation can be evaluated quantitatively with von Frey filaments. The sharp end of a broken sterile wooden Q-tip is a convenient and safe tool for testing sensation to pinprick. The following are often observed in neuropathic pain conditions:
Hyperesthesia–increased sensitivity to stimulation, excluding the special senses
Dysesthesia–an unpleasant abnormal sensation, either spontaneous or evoked
Allodynia–pain caused by a stimulus that normally does not provoke pain
Hyperalgesia–an increased response to a stimulus that is normally painful
Hyperpathia–a painful syndrome characterized by an abnormally painful reaction to stimulus (especially a repetitive one), as well as increased threshold
Summation–a repetitive pinprick stimulus applied at intervals of more than 3 seconds, with a gradually increasing sensation of pain with each stimulus
(v) Mental status examination
The mental status examination is a part of the neuropsychiatric assessment. Examine level of consciousness, orientation, speech, mood, affect, attitude, and thought content. The Mini-Mental Status Exam (MMSE) of Folstein is a useful guide for documenting level of mental function. There are five areas of mental status tested: orientation, registration, attention and calculation, recall, and language. Each correct answer is given one point. A maximum score on the Folstein is 30. A score of less than 23 is abnormal and suggests cognitive impairment.
III. INCONSISTENCIES IN THE HISTORY AND PHYSICAL EXAMINATION
Inconsistencies in the history and physical examination, vague description of symptoms, and evidence of intense suffering, together with inappropriate pain behavior, may suggest symptom exaggeration, malingering for compensation, and other gains or psychogenic pain. The frequently cited Waddell nonorganic signs may raise suspicion in patients with lower back pain. It may be warranted to proceed with the SF-36 or another instrument designed to identify underlying problems or issues. The Waddell nonorganic signs are grouped into five categories:
Widespread superficial sensitivity to light touch over lumbar spine
Bone tenderness over a large lumbar area
Axial loading, during which light pressure is applied to the skull in the upright position
Simulated rotation of lumbar spine with the shoulders and pelvis remaining in the same plane
Greater than 40 degrees difference in sitting versus supine straight leg raising
Motor: generalized giving way or cogwheeling resistance in manual muscle testing of lower extremities
Sensory: nondermatomal loss of sensation to pinprick in lower extremities
Disproportionate pain response to testing (pain behavior with assisted movement using cane or walker, rigid or slow movement, rubbing or grasping the affected area for more than 3 seconds, grimacing, sighing with shoulders rising and falling)
The history and physical examinations are the foundations for pain evaluation and treatment and essential elements of good pain management. They need to be tailored to the individual patient, the complexity of the pain problem, and the medical condition of the patient. The standard history and physical examinations outlined here can be applied to most patients presenting in the pain clinic.
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