Pain Assessment, Diagnosis, and Evaluation
History and measures
Start with the patient's story: onset, quality, location, radiation, timing, aggravating and relieving factors, associated symptoms, function, sleep, mood, and prior treatments. Use a numeric rating scale for immediacy but pair it with function and a multidimensional instrument such as a brief pain inventory when possible. Pain intensity is one domain, not the diagnosis. Screen for psychosocial risk, catastrophizing, and sleep disturbance because they predict disability.
Examination and red flags
Examine gait, posture, range of motion, tenderness, and neurologic function. Look for red flags: progressive weakness, bowel or bladder dysfunction, saddle anesthesia, fever, unexplained weight loss, cancer history, trauma, or night pain. These change urgency, not just the analgesic. Distinguish radicular from somatic patterns and identify myofascial or visceral referrals. Imaging is indicated when findings will change management, not to validate pain.
Traps
A common trap is treating a high pain score as an indication for escalation without reassessment. Another is labeling requests for relief as drug-seeking when the real issue is untreated pain, anxiety, or poor access. Screening tools support, but do not replace, clinical diagnosis. Do not document only pain controlled without documenting function.
Worked example
A 58-year-old presents with two days of severe low back pain, new urinary retention, and bilateral leg weakness. The pain score is 9/10, but the decisive finding is the red-flag triad. Rule of thumb: new bowel or bladder symptoms with saddle anesthesia or bilateral neurologic deficits require urgent imaging and specialty referral, not a routine opioid refill.