School of Medicine

Script Example

Master
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(Nancy Owens, Age 44)

Chief Complaint: "I’ve had some back and leg pain and want help for it."

Identifying Data: College-educated accountant; workload stressful at times; married, one child, good home life.

Scenario: Your low back/left leg pain began about three months ago. You had a similar problem during the last few months of your pregnancy (your child was born seven years ago), but then none until three months ago. You consider yourself an athlete and can’t run due to pain and intermittent numbness and tingling (pins and needles feeling) in left leg.

Patient Profile: Concerned/anxious about this problem. You are in pain during the interview, but it is tolerable. Sitting is very uncomfortable, so shift around after several minutes. Bend forward slightly when sitting (put hands under knees—having knees higher than pelvis feels better). When walking, do so slowly with pelvis tilted forward. You have slow movements with some stiffness in your back. Standing tolerance is 10-15 minutes. You bend over and rotate slowly. If asked to lie down: bring your knees up and flatten your back for comfort.

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History of Present Illness

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When did it start? Three months ago.

How did it come on? It gradually started over a few days, on and off.

Did you have any injury to bring this on? No

How frequent is the pain? It was every few days, but now it’s almost daily.

How long does it last? At least a day; sometimes now longer than a day.

Where is the pain? Lower back, especially left side and left leg, along back and side of leg into side of foot.

If probed further: Currently have back and leg pain together, but can have back pain without leg pain.

Describe the pain. Dull and achy.

How bad is the pain? On a scale of 1-10 (10 as the worst), it ranges from 3-; now it’s at 5.

Does it interfere with your life? After an hour at your desk you get stiff. Haven’t been able to do your usual exercise. Can’t bend over to pick things up. Housework is painful (like doing laundry). Shifting painful when driving.

Relieving factors? Lie on side and sit with feet up.

Aggravating factors? Exercise, standing, bending over, and stress

Back/leg pain during pregnancy? Yes. It was like this, but it went away gradually after the child was born.

Any other symptoms beside pain? Intermittent numbness and tingling in left leg , and left leg feels weak.

Where is the numbness? The same area as the pain.

How often does numbness occur? Up to once a week lately; less often than the pain.

How long does numbness last? A few hours at a time.

Does the numbness accompany the pain? Sometimes have numbness without pain.

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Past Medical History

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Answer NO to the following: allergies, surgery, tobacco, intravenous or recreational drugs

Medications? None now. Tried a non-steroidal anti-inflammatory (Motrin, over-the-counter), Hasn’t really helped much so just take it on an off.

Alcohol? Socially, one or two glasses of wine a week

Hospitalizations? Childbirth, seven years ago.

Exercise? I usually swim, walk, and run - mile a day before the pain. Haven’t been able to because of the pain

Script covers all problems/abnormalities. If asked about any other problems, everything is normal.

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Family History

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Live with spouse and one child; parents-living; one sibling – an older sister. No history of hypertension, cancer or coronary artery disease in family; father and sister have allergies-hay fever.

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Questions to Ask

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  • What do you think I have?
  • Is this a herniated disc?
  • Will I need surgery?