A really effective way of taking a history is to ensure you’ve covered all the red flag symptoms. As a junior doctor you’re not expected to know the minutiae of how to treat every condition, but you most certainly are expected to be able to spot an emergency, or potentially very serious condition. Learning red flags, and ensuring you’ve ruled them out in the history is a great way to reassure yourself, your consultant and your patient that it’s not likely to be a serious problem. Back pain is one of those symptoms that is incredibly common, and 99% of the time is not due to a serious underlying pathology, but when it is, you absolutely need to spot it.

So here’s a story to remember the red flags of back pain!

Mr back pain is normally a fairly spritely young man. One day he wakes up drenched in sweat with this splitting pain in his lower back. It’s sending shooting pain down both of his legs and when he tries to climb out of bed he realises his muscles aren’t working and he slumps to the ground in a heap.

• New pain at young age
• Nocturnal pain
• Night sweats
• Bilateral symptoms
• Neurological symptoms

He lies in the foetal position for a while, contemplating his predicament, and finally summons up enough strength to climb to his feet. He realises that he hasn’t been to the loo yet and he is bursting for a pee, so he begins to shuffle, very stiffly, towards the bathroom. However before he manages to reach the toilet he sneezes and urinates all over the floor.

• Pain does not reside when in foetal position
• Urinary incontinence
• Morning stiffness

It’s puzzling as to why his back hurts.  He hasn’t bashed it recently and doesn’t do any sport that would strain his back. He has had a cold with a fever for the last few days but it hadn’t been that bad, certainly not the worst he’d ever had. He had been diagnosed several years ago with acute myeloid leukaemia but had since made a very good recovery.

• No history of trauma
• Recent illness/immunosuppression
• History of malignancy

He stands on the scales and is happy that he’s lost weight without even trying, even though his belly seems to have gotten bigger, but the pain in his back hasn’t got any better. After a while his calves start to hurt so he decides to go back to bed.

• Weight loss (unintentional)
• Abdominal mass
• Unremitting pain
• Claudication symptoms

Back Pain red Flags

– Acute pain in over 55 or <30

– Neurological signs

– Claudication symptoms

– Limb ischaemia

– Constant pain/progressive pain

– Abdominal mass

– Nocturnal pain

– No relief from foetal position

– Alternating or bilateral pain

– Fever, malaise

– Weight loss

– Recent or current infection

– Immunosuppression

– Non mechanical history