History and physical examination |
- Identify possible pain etiology
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- Identify comorbidities that may affect treatment options
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- Examine for allodynia and/or sensory changes in painful body part
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- For patients who use opioids or patients with risk factors for opioid misuse or use disorder:
- Check PDMP
- Screen for opioid risk with ORT, SOAPP, COMM, or similar
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Body diagram |
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- For patients with multisite pain, screen for chronic widespread pain disorders with Widespread Pain Index and Symptom Severity Score
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Pain history |
OLDCARTS |
- Onset ("When did your pain start?")
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- Location ("Where does it hurt?")
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- Duration ("How long does your pain last?")
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- Character ("How does your pain feel?", ie, aching, burning, shooting, tingling)
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- Alleviating/Aggravating ("What makes your pain better/worse?") and Attribution ("What do you think is the cause?")
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- Radiation ("Does this pain spread anywhere else?")
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- Temporal pattern ("Does your pain vary over the course of a day?")
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- Symptoms associated ("How does your pain impact your physical function, your mood, your sleep?")
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Pain severity and impact |
Pain intensity, pain interference with enjoyment of life and general function (PEG) |
- What number (0 to 10) best describes your pain on average in the past week?
| ________________ |
- What number (0 to 10) best describes how, in the past week, pain has interfered with your enjoyment of life?
| ________________ |
- What number (0 to 10) best describes how, in the past week, pain has interfered with your general function?
| ________________ |
Mood assessment |
PHQ-4[1] |
Over the past 2 weeks, have you been bothered by these problems? | Not at all | Several days | More days than not | Nearly every day |
- Feeling nervous, anxious, or on edge
| 0 | 1 | 2 | 3 |
- Not being able to stop or control worrying
| 0 | 1 | 2 | 3 |
- Feeling down, depressed, or hopeless
| 0 | 1 | 2 | 3 |
- Little interest or pleasure in doing things
| 0 | 1 | 2 | 3 |
Scoring: - Add total score
- For score >5, screen for anxiety, depression, and post-traumatic stress, with GAD-7, PHQ-9, and PTSD-5
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Sleep assessment |
Sleep initiation and maintenance |
- Does pain interfere with falling asleep?
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- Does pain interfere with staying asleep?
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Screen for obstructive sleep apnea – STOP-Bang[2,3] |
Yes | No | Snore – Do you snore loudly (loud enough to be heard through closed doors, or your bed partner elbows you for snoring at night)? |
Yes | No | Tired – Do you often feel tired, fatigued, or sleepy during the day? |
Yes | No | Observed – Has anyone observed you stop breathing or choking/gasping during sleep? |
Yes | No | Pressure – Do you have or are you being treated for high blood pressure? |
Yes | No | Body mass index >35 kg/m2? |
Yes | No | Age older than 50 years? |
Yes | No | Neck size large (male: ≥17 inches, female: ≥16 inches)? |
Yes | No | Gender = male? |
Scoring: - Low risk of OSA: Yes to 0 to 2 questions
- Intermediate risk of OSA: Yes to 3 to 4 questions
- High risk of OSA: Yes to ≥5 questions
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