Diagnosis: History and Physical Examination
When you visit the San Diego Center for Spinal Disorders (SDCSD), our medical staff will take a complete and thorough history, and we will conduct a physical examination. The history and the physical examination are two very important steps towards an accurate diagnosis of your spinal condition. Your physician will use the information gained in these assessments to decide if further diagnostic tests are needed, and which tests are appropriate.
During your first visit to SDCSD you will meet with a nurse or doctor, who will ask you a series of questions about your symptoms, your past medical history, and other relevant details. Although the specific items that we discuss in taking your history will depend on your condition, some of the questions that you may be asked include:
Symptoms and Complaints
- Why are you visiting SDCSD?
- When did your symptoms begin?
- Have you received treatment or evaluation from another physician?
- What was the response to previous treatments?
- Are your symptoms related to an injury or accident? If so, when did the injury occur and what type of care did you receive?
- Where is your pain located? Where does it begin? Does the pain travel to other parts of the body?
- How often do you experience this pain?
- When do you experience this pain (e.g. at night, when standing)?
- Rate the severity or intensity of your pain.
Medications and Allergies
- What medications have you tried to relieve your pain?
- Was / is this medication effective in relieving your pain?
- What are the current medications you take (including dose, number of pills and number of times per day the medication is taken)?
- Are you allergic to any medications?
- Are you allergic to any non-medication substance, such as iodine, dye, or shellfish?
Past Medical History
- Are there any other past or current medical conditions for which you have received treatment?
- Have you had any previous surgeries?
- If so, what was the outcome of the surgery? Did you experience any complications from the surgery?
- Does anyone in your family have a history of spinal disorders?
We may also ask you questions about your living situation, your occupation, and whether or not you smoke or use drugs or alcohol. Although these questions are personal in nature, accurate information is essential for us to formulate our diagnosis and an effective treatment plan to bring you back to health!
During your first visit to SDCSD, we will also conduct a thorough physical examination. We can determine a lot about your spinal condition simply through observing the way you walk, stand or sit. In addition, we will assess your general medical health.
A typical physical examination may include all or some of the following elements:
- Assessment of your height, weight and vital signs (e.g. temperature, heart rate, blood pressure)
- Inspection of your skin.
- Examination of your breathing and your abdomen.
- Examination of your gait (the way you walk). You may be asked to walk on your toes or your heels to assess the health of your nerves.
- Examination of the contour of your spine. You will be asked to stand while the nurse or doctor views the curves of your spine from the back and the side.
- Range of motion assessment. You may be asked to bend forward and backward, and to bend from side to side as far as possible. You may also be asked to rotate your neck in each direction. During the range of motion assessment, your nurse or doctor may place his or her hands on your hips or shoulders to stabilize your body.
- Palpation of the spine. Your nurse or doctor may apply light pressure to your spine to locate and document areas of tenderness or spasms and to assess for any masses or swelling.
- Straight leg raising test. You may be asked to raise or extend your legs from a sitting or lying position. This helps us to assess for nerve root tension. The examiner may assist you by gently raising the leg. You'll be asked to note the point at which you experience pain as your leg is raised.
- A neurologic examination, which tests your reflexes, sensation, and motor strength. Sensation is assessed by gently touching a pin to the skin, and is usually tested in both your arms and your legs.
You will usually be asked to wear a hospital gown for the physical examination. Although wearing a hospital gown can be an uncomfortable experience for some patients, we do our best to ensure your comfort and respect your privacy throughout the exam.
Please be sure to let your nurse or physician know if you experience any pain during the physical exam. This discomfort can reveal important information about your spinal disorder.
After your history and physical examination, the spine team at SDCSD will review your condition and order the appropriate diagnostic tests, which may include radiological studies such as x-rays, MRI, CT, myelogram, discogram, or bone scan. For some conditions, we may order diagnostic injections as well.
At SDCSD, we firmly believe in taking a personalized approach to your spine care. This means that we will listen carefully to the information you give us in your history; we will take into consideration all aspects of your exam and diagnostic studies; and the medical staff will work with you as a team to formulate a comprehensive treatment plan. Please communicate truthfully and regularly with us throughout your diagnosis and treatment, so that we can provide the best possible care!