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INSTRUCTIONS FOR THE DOCTOR

This is a short case.

Please take a focused history. Request the findings of an appropriate physical examination from the facilitator and explain your management plan to Hope. No further investigations are available.

Scenario

Hope Briganza is a 26-year-old child care worker who is a regular patient of the practice. She is generally healthy. She presented to your colleague 10 days ago and he diagnosed a lower back strain.

Your colleague’s clinical notes from her previous visit reads:

  • three days right LBP without red flags

  • works in child care—lifts children all day

  • past mild episodes only

  • otherwise well; only on OCP

  • physical examination unremarkable

  • assessment: acute mechanical LBP/muscle strain

  • plan: rest (medical certificate 1/7); simple analgesia prn; local heat prn

  • r/v no better.

The following information is on her summary sheet:

  • Age

  • 26

  • Past medical history

  • Oral contraception

  • Tonsillectomy (age 12)

  • Medication

  • Ethinyloestradiol 30 mcg/levonorgestrel 150 mcg (Levlen ED) 1 mane

  • Allergies

  • Nil known

  • Immunisations

  • Up-to-date

  • Cervical screening

  • Up-to-date

  • Social history

  • Non-smoker

  • Alcohol—one or two drinks a week

  • Family history

  • Hypertension

  • Ischaemic heart disease

  • Osteoarthritis.

INSTRUCTIONS FOR THE PATIENT, HOPE BRIGANZA

You have had about two weeks of right-sided lower back pain. You came to see another doctor at this practice 10 days ago. He diagnosed a back strain and suggested rest, heat packs and paracetamol. He thought it could be related to lifting children (you work in child care) so he gave you a day off work. The pain is in your right flank (loin) and is dull and deep. It is constant and is not affected by anything you do. It occurs at rest as well as with movement. You don’t recall any particular incident or injury but you do bend and lift children all day. You’ve taken some paracetamol but it doesn’t help much. You have had episodes of mild lower back pain previously, but they were brief and usually only when you had done too much in the garden or at sport. This pain feels different as it is higher up, and constant—you’re worried it might be something serious.

If asked, you do have mild urinary frequency (day and night) and urinary urgency but no incontinence. If asked about fever or temperatures you do sometimes feel hot and cold but you haven’t checked your temperature. You have been feeling tired and washed out over the last week or so. There has been some nausea and anorexia but no vomiting or change in your bowels.

You live with your boyfriend who has been your only sexual partner for the past four years. You are on the contraceptive pill (Levlen) and remember to take this every day. Your last period was about a week ago and was normal. There are no symptoms of pregnancy and your ...

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