History Taking · Intermediate · Surgery

Lower Back Pain with Difficulty Moving

Practise this PLAB 2 history taking station on Mechanical Lower Back Pain. 8-minute voice AI simulation with feedback on all 3 marking domains.

Clinical scenario

You are an FY2 doctor in the GP surgery. Mr Jared Moran, a 48-year-old man, has presented with acute lower back pain. He is struggling to move and is in visible discomfort. Please take a history to exclude red flags and discuss conservative management.

Background notes: PMH: Recurrent non-specific lower back pain x 10 years (mild, self-limiting), Appendicectomy age 22

What this station tests

  • Systematic red flag screening: cauda equina (saddle anaesthesia, bladder/bowel, bilateral weakness), malignancy (weight loss, night pain), infection (fever), fracture (trauma, steroids)
  • No imaging for non-specific back pain: NICE does not recommend X-ray or MRI without red flags
  • Active management over bed rest: gentle activity within pain limits is superior to bed rest
  • Self-employment context: financial pressure, no sick pay, practical return-to-work advice
  • Cauda equina safety netting as the critical take-home message: saddle anaesthesia, bladder/bowel changes require 999

How to use your 8 minutes

  • 0-1 min — Introduction: Introduce yourself, confirm identity, open question. 'What's brought you in today?'
  • 1-4 min — Systematic History: Presenting complaint detail (SOCRATES for pain, timeline, severity). Systems review. PMH, medications, allergies.
  • 4-6 min — Context and ICE: Social history (smoking, alcohol, occupation, living situation). Family history. Ideas, Concerns, Expectations.
  • 6-7 min — Summary and Plan: Summarise findings back to patient. Share differential/working diagnosis. Outline investigation and management plan.
  • 7-8 min — Closing: Safety netting with specific red flags. Arrange follow-up. Check for questions.

Consultation approach

The opening

Acute lower back pain stations primarily test red flag screening. The candidate must systematically exclude cauda equina, malignancy, infection, and fracture before confidently diagnosing mechanical back pain. Mr Moran is 48, a self-employed carpenter, with 3 days of acute lower back pain. He is in visible discomfort and cannot afford to be off work. Open with: 'Mr Moran, I can see you are in a lot of pain. Tell me what happened and when it started.'

Core approach

Characterise the pain. Acute onset 3 days ago on waking, lower lumbar region, bilateral, deep aching, worse with movement, better with rest. No radiation to legs. He has had minor back pain on and off for 10 years (occupational). This is the worst episode. No specific injury or lifting event recalled.

Systematic red flag screening (the core of this station). Cauda equina: any saddle anaesthesia (numbness around buttocks or genitals)? Any bowel or bladder changes (incontinence, retention)? Any bilateral leg weakness? All absent. Malignancy: any unexplained weight loss? Night pain that wakes him? Previous cancer history? All absent. Infection: any fever? Any recent procedure? IV drug use? Immunosuppression? All absent. Fracture: any trauma? Osteoporosis risk factors? Steroid use? All absent.

Assess function. He cannot bend, twist, or lift (critical for carpentry). He cannot get comfortable. Sleep is disrupted by position changes. He is self-employed with no sick pay and is under financial pressure. This context matters for management.

Closing and safety netting

Confident diagnosis: 'Mr Moran, based on the pattern of your pain and the absence of any concerning features, this is mechanical lower back pain. This means the muscles and ligaments in your back are strained. It is painful but it is not dangerous, and it will improve.'

Management: regular paracetamol and ibuprofen (alternating, with food). Do not advise bed rest: 'Keeping gently active is better than lying in bed. Move within your pain limits.' Avoid heavy lifting until settled. Heat packs for comfort. Consider short course of muscle relaxant (diazepam 2mg TDS for 3 to 5 days) if severe spasm. No imaging needed: NICE does not recommend imaging for non-specific back pain without red flags.

Address his work concern: 'Most episodes of back pain improve significantly within 2 to 4 weeks. You may be able to return to lighter duties sooner.' Self-certification for the first 7 days, fit note if needed beyond that. Safety net: 'If you develop leg weakness, numbness around your bottom, or any bladder or bowel changes, come in immediately or call 999 as these would need urgent assessment.'

How examiners mark this station

Examiners will focus on the thoroughness and structure of your history taking for mechanical lower back pain. Domain 1 (Data Gathering) carries the most weight: expect marks for systematic coverage of presenting complaint, red flags, PMH, medications, social and family history. Domain 2 (Clinical Management) requires a clear differential, appropriate investigations, and a safe management plan with safety netting. Domain 3 (Interpersonal Skills) is assessed throughout: genuine exploration of ICE, active listening, empathic responses, and clear communication without jargon.

Domain 1: Data Gathering, Technical and Assessment Skills (Primary focus)

Scores well: All red flags systematically screened (cauda equina, malignancy, infection, fracture). Pain characterised. Functional impact assessed. Occupational history relevant to management.

Costs marks: Incomplete red flag screening. Not asking about saddle anaesthesia. Not asking about bladder/bowel. Missing malignancy screening.

Domain 2: Clinical Management Skills (Primary focus)

Scores well: No imaging ordered (correct per NICE). Multimodal analgesia. Active management advised (not bed rest). Cauda equina safety netting. Work return timeline. Fit note if needed.

Costs marks: Ordering imaging. Advising bed rest. No cauda equina safety netting. No return-to-work discussion.

Domain 3: Interpersonal Skills (Throughout)

Scores well: Acknowledging financial pressure. Providing realistic recovery timeline. Confident reassurance (painful but not dangerous). Addressing slipped disc concern.

Costs marks: Dismissing work concern. Being vague about recovery. Not providing reassurance.

Common examiner feedback (and how to fix it)

Did not gather sufficient information to make an adequate assessment of the patient's condition

Fix: Use a consistent framework for every history. After covering the presenting complaint, systematically move through PMH, drug history, social history, family history, and ICE. Keep a mental checklist.

Did not identify the patient's problems and/or did not develop a management plan adequately

Fix: Reserve the final 2 minutes to summarise your findings, share your working diagnosis with the patient, and outline your investigation and management plan including safety netting.

Common mistakes in this station

  1. Ordering imaging without red flags. Requesting an X-ray or MRI for non-specific mechanical back pain without red flag features is unnecessary and not recommended by NICE. Candidates who order imaging demonstrate over-investigation.
  2. Not screening for cauda equina specifically. Asking about leg pain is not enough. Candidates must specifically ask about saddle anaesthesia and bladder/bowel function. These are the two questions that distinguish an emergency from mechanical pain.
  3. Advising bed rest. Bed rest prolongs recovery in mechanical back pain. NICE recommends staying active within pain limits. Candidates who advise rest demonstrate outdated management.

Resitting PLAB 2?

If you have previously struggled with history taking stations, focus on building a consistent systematic framework that you apply to every case. Practise structuring your history into clear phases (presenting complaint, systems review, PMH, social, ICE) so that even under pressure, you cover all domains. Many resitters lose marks not on knowledge but on organisation and time management.

Example opening

Good morning/afternoon, my name is Dr [Name], I'm one of the doctors here today. Could I confirm your name and date of birth please? Thank you. So, what's brought you in to see me today?

Frequently asked questions

How do I approach the consultation in this mechanical lower back pain station?

Acute lower back pain stations primarily test red flag screening. The candidate must systematically exclude cauda equina, malignancy, infection, and fracture before confidently diagnosing mechanical back pain. Mr Moran is 48, a self-employed carpenter, with 3 days of acute lower back pain.

What does a strong performance look like to the examiner in this station?

Strong performances show: All red flags systematically screened (cauda equina, malignancy, infection, fracture). Pain characterised. Functional impact assessed. Occupational history relevant to management. Weak performances: Incomplete red flag screening. Not asking about saddle anaesthesia. Not asking about bladder/bowel. Missing malignancy screening.

What is the biggest pitfall in this mechanical lower back pain station?

Ordering imaging without red flags. Requesting an X-ray or MRI for non-specific mechanical back pain without red flag features is unnecessary and not recommended by NICE. Candidates who order imaging demonstrate over-investigation.

How should I prepare for mechanical lower back pain if I have never seen it in practice?

Structure beats experience here. Focus on no imaging for non-specific back pain: NICE does not recommend X-ray or MRI without red flags. The written guidance on this page covers the full approach, and practising the consultation aloud builds the fluency the examiner is listening for.

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