9: Pain assessment

Pain Assessment in History Taking

Pain assessment is a critical component of the medical history, providing essential clues to diagnosis and guiding management. A thorough evaluation goes beyond simply asking "Where does it hurt?" and requires a structured approach to understand the pain's nature, impact, and context. The widely used SOCRATES mnemonic provides a valuable framework:

• Site: Precisely locate the pain. Ask the patient to point to it. Does it radiate anywhere?
• Onset: When did it start? Was it sudden or gradual? What were they doing?
• Character: Describe the quality (e.g., sharp, stabbing, dull, aching, burning, throbbing, crushing).
• Radiation: Does the pain spread from its original site (e.g., chest pain radiating to the jaw/arm)?
• Associated Symptoms: Are there other symptoms like nausea, vomiting, sweating, fever, numbness, weakness, or changes in bowel/bladder function?
• Time Course: How has it changed since onset? Is it constant or intermittent? If intermittent, frequency and duration of episodes?
• Exacerbating/Relieving Factors: What makes it worse (e.g., movement, breathing, eating, stress)? What makes it better (e.g., rest, specific positions, medications)?
• Severity: Quantify the intensity. Use a validated scale consistently (e.g., 0-10 Numeric Rating Scale where 0 is no pain and 10 is the worst imaginable, or a Visual Analog Scale). For children or those with communication difficulties, use age-appropriate tools like the Wong-Baker FACES Pain Rating Scale.

Crucially Assess Impact: Determine how the pain affects the patient's function – ability to work, sleep, perform daily activities, exercise, or engage socially. Explore the patient's own thoughts and concerns about the cause of the pain and its implications.

Special Considerations

• Non-Verbal/Impaired Cognition: Rely more heavily on behavioral cues (facial expressions, guarding, agitation, vocalizations) and reports from caregivers. Use observational pain scales (e.g., PAINAD in dementia).
• Cultural Background: Be aware that cultural norms can significantly influence pain expression and reporting. Avoid assumptions.
• Chronic Pain: Explore duration (>3 months), previous treatments and their effectiveness, impact on quality of life, mood (anxiety/depression), and coping strategies.
• Opioid History: If relevant, document current/past opioid use and concerns about dependence or misuse.

Accurate pain assessment hinges on empathic communication and careful listening. Document the findings clearly and objectively, including the specific scale used for severity. This comprehensive approach is fundamental for effective diagnosis, treatment planning, and evaluating therapeutic response.