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The back pain problem

Case history 1

Mr Jones is a 52 year old, semi-skilled worker. He attends the surgery regularly, and suffers with mild, generalised osteoarthritis. He has attended the local Orthopaedic clinic on a couple of occasions, but you don't remember the full details, apart from him having had back pain. When you arrive at the house, Mr Jones is lying on the lounge floor. He was changing the TV channel, when he felt a click in his back and was unable to move. He is now lying on his back with a cushion under his head. Mrs Jones is panicking, and a neighbour is there to help.

He is complaining of lumbo-sacral back pain, spreading up into his dorsal region and down into his buttocks. On examination he lies stiff and motionless, and his questions indicate that he is very frightened about what is happening to him. He is panicking and sweating. Neurological examination of his lower limbs reveals variable power, because of pain in his back and right leg, normal sensation and severe back pain on straight leg raising.

Question A

Do you require more information?

What action should be taken and what treatment recommended?

What should be explained to the patient?

You are called to see the patient 2 weeks later. He has been in bed for the full 2 weeks, and his wife brings him a urine bottle, though he goes to the toilet to open his bowels. He is complaining of low back pain which is aching in nature. There is no weakness. He has normal reflexes, and bladder and bowels function normally. On examination he looks comfortable, but complains of pain on movement. Television, telephone, kettle and toast are all by his bedside, and his wife and children are in attendance.

Question B

Do you require more information?

What action should be taken and what treatment recommended?

What should be explained to the patient?

Mrs Jones rings you one week later. Her husband has mobilised a little and is now in "absolute agony". He can't move.

Question C

Do you require more information?

What action should be taken and what treatment recommended?

(ie, Would you visit, refer to the hospital, send to Casualty or wait for things to settle down?)

What should be explained to the patient and family?

For the purpose of this exercise, the action you take in Section C is a home visit. Mr Jones gives a 2 day history of pain in the right leg, spreading down into the foot. On examination, there is a positive sciatic stretch test on the right, and the right ankle jerk is absent. There is numbness over the lateral border of the right foot, and eversion of this foot is very weak.

Question D

Do you require more information?

What action should be taken and what treatment recommended?

What should be explained to the patient?

 


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