Back Pain Scenario 1
( Chronic low back pain)
Mrs Linda Sharpe age 63 years old.
Mrs Linda Sharpe has been struggling with back pain for some time and feels it is getting worse. She works packing boxes in a warehouse 3 days a week for 8 hour shifts, sometimes in very cold conditions. She gets spasms in her back and has pain all the time. On her days off , she babysits for her grandchildren aged 2 and 4 and has to pick the older one up from nursery.
Her husband is unemployed with complications of diabetes and an amputation.
She gets depressed with the pain and comfort eats. It is the only relief she gets.
She gets constipation with the pain killers , so only takes them now and then, but takes them at night to help her sleep.
She has made an appointment with the Practice nurse/ contacted the Social Services Department saying that she feels she cannot work any longer with her back pain.
She has already been to the Pharmacist who gave her some lactulose for her bowels, but that gives her wind. It tastes sweet and she is worried she will put on more weight or get diabetes like her husband.
The Pharmacist/Practice Nurse/ Social Worker talk to her, listen to her story and advise her to see the GP to assess her back pain.
Mrs Sharpe makes an appointment to see the GP/Nurse Practitioner
Her past medical history is as follows:
February 2015 Right shoulder impingement
May 2014 MRI brain normal
February 2014 MRI lumbar spine – L4/5 and L5/S1 disc dehydration. Moderate degenerative disc height loss L5/S1. L3/4 minimal facet arthrosis. L4/5 mild to moderate facet joint arthrosis with minimal diffuse disc bulge. L5/ S1 mild right neural foraminal stenosis
January 2011 BMI 39.3
January 2011 Laryngoscopy normal
October 2008 Hypertension
March 2003 Breast reduction
November 1996 Low back pain – epidural injection
Medication
Bendroflumethiazide 2.5 mg daily
Orlistat 120 mg tds
Cocodamol 30/500mg
Dr Weary sees Mrs Sharpe.Mrs Sharpe has asked him for a certificate dating back 3 months when her pain started . She has not seen a doctor in this period. She said she feels she should medically retire.
She wants to see an Orthopaedic surgeon for pain relief and to confirm to her employers that she has a bad back. She is troubled with wind and says the pain killers are not working.
TASK 1
- In your role, what questions would you like to ask Mrs Sharpe about her back pain?
- What red flags would you specifically ask for?
- What “yellow flags” have you identified?
Dr Weary goes on to examine Mrs Sharpe.
TASK 2
Outline your examination of Mrs Sharpe and key features which would help you identify red flags or yellow flags.
Mrs Sharpe takes a while to get out of her chair and is almost tearful with the pain. She can barely bend forward and her finger tips reach just above her knees. There is generalized tenderness over all the muscles in her back but no bony tenderness.
She cannot raise her legs without great difficulty. Sensation appears normal. You cannot elicit any reflexes but think this is because she is holding her muscles in a tense way.
Dr Weary is running out of time and is running 30 minutes late. He is tempted to write a certificate, increase her analgesia and give her senna and to refer to the Orthopaedic surgeon as requested.
TASK 3
- What are the advantages and disadvantages of this option?
Dr Weary takes a sharp intake of breath, focuses on his breathing and wonders if he can manage this in a different way.
TASK 4
- Does Mrs Sharpe need any further investigations?
- How do you address Mrs Sharpe’s concerns without giving in to her every request?
- What interventions may help Mrs Sharpe? Consider self help/community support/wellbeing advice/pharmaceutical measures/physical therapies/interventional therapies/surgery
- Which resources would be the most effective and how do you access them?