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Location: You are a final year medical student in a GP practice.

 

Patient: Mr Fowler has come to see you because of back pain.

 

Task: Please take a history and explain the management options. For the purposes of this station, assume the examination is normal.

Note to actor: Try to restrain yourself from volunteering too much information – you may do so when prompted (that is, by a specific question, not a general one). If a student is on the wrong line of clinical reasoning do not fuel this line of thinking, state no to the question as being ambiguous may prompt further questioning and does not allow the student to be appropriately tested.

 

Your role

Your name is Ben Fowler. You are a 34 year old boiler engineer. You have come to the GP because of back pain.

 

History of presenting symptoms

Information to be volunteered at the start

You started having back pain 2 weeks ago. It is in the lower part of your back in the centre and slightly to the left of the spine. It gets a lot worse when you move or lift heavy objects. It came on gradually but you can remember doing some heavy lifting the day before. You have tried bed rest for the last few days but it doesn’t seem to have helped.

 

Information to be given if asked

The pain is really bad and just even walking around causes severe pain. When you move the pain is 10/10 and you ‘wouldn’t wish it on your worst enemy’. The pain is constant and is not worse at particular times during the day. Taking aspirin and having hot showers are the only things which help a little.

 

You are otherwise well. The pain does not go down your legs. You have no altered sensation and your leg muscles are working normally. You have had no weight loss, fevers or sweats. You are passing urine and stool normally.

 

Background information

Past medical history

None.

Medications and allergies

None.

Family history

Your mother died of a heart attack at 70 years of age. Your dad has arthritis. Your brother is disabled after a motorcycle accident.

Social and personal circumstances

You are a boiler engineer who often has to lift heavy tanks and has been doing a lot of overtime. You also regularly go to the gym to lift weights. You smoke 20 cigarettes per day and drink 6-10 cans of beer on the weekend. You have never done illegal drugs. You have had 12 sexual partners in your life and are currently single and dating. You play football in the village 5-a-side team.

 

Your ideas, concerns and expectations

After reading online, you are concerned you have a herniated disc. If the doctor says it is not, ask how they know. You are sure you need an MRI scan to investigate the pain. If the doctor suggests you do not need a scan, question this.

 

Questions for the doctor

You would like to know about the treatment options, specifically surgery.

Category Question
Done
Excellent
Intro Introduction
Washes hands
Introduces self
Checks patient’s name
Gains consent


PC Presenting complaint
Site
Onset
Character
Radiation
Associated symptoms
Timing
Exacerbating factors
Severity


Red flags Back pain red flags
Cauda equina: urinary retention/incontinence, faecal incontinence, bilateral leg pain, severe/progressive neurological deficit, decreased anal tone, saddle paraesthesia
Infection or cancer: age <16 or>55 years at onset, cancer history, weight loss, fever, night sweats, injecting drugs, immunosuppression
Fracture: trauma
Spondyloarthropathy: early morning stiffness, night pain, worse with rest


SR Relevant systems reviews
Lower limb neurological symptoms: pain, numbness, paraesthesia, weakness


PMH Past Medical History
Past medical history appropriately explored


DH Drug History
Drug history appropriately explored
Drug allergies


SH Social History
Social history appropriately explored


FH Family history
Family history appropriately explored


Management Management explanation
Analgesia ± muscle relaxants
Ice/heat packs
Light mobilisation
Physiotherapy
Avoid heavy lifting
Advises to return if any red flags or fails to improve in 6 weeks


Comms Communication
Builds rapport
Starts with open questions and then progresses to closed questions (coning)
Uses signposting
Avoids leading questions
Avoids jargon
Empathetic
Summarises at end
Thanks patient


ICEF ICEF
Explores ideas, concerns, expectations, feelings
Asks patient if they have any questions


Question What are the serious cases of back pain and their red flags?
Cauda equina: urinary retention/incontinence, faecal incontinence, bilateral leg pain, severe/progressive neurological deficit, decreased anal tone, saddle paraesthesia
Infection or cancer: age <16 or>55 years at onset, cancer history, weight loss, fever, night sweats, injecting drugs, immunosuppression
Fracture: trauma
Spondyloarthropathy: early morning stiffness, night pain, worse with rest



Submit your answers to get your score.

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