+++
INSTRUCTIONS FOR THE DOCTOR
++
++
Please take a focused history from Doug. Request the findings of an appropriate physical examination and investigations. Explain your provisional diagnosis and initial management plan to Doug.
++
Scenario
Doug Sullivan is a 32-year-old man who has been a patient of the practice for 12 months.
He has a history of intravenous drug use (mainly opiates) and alcohol dependence. He has been off illicit drugs and alcohol for two years and is compliant with a methadone maintenance program. He is on telmisartan (Micardis) for hypertension and esomeprazole (Nexium) for gastro-oesophageal reflux.
He is divorced with three children who live with their mother on the coast. He is not working consistently but sometimes helps his father who runs a contract construction crew.
He presented last month with back pain, which he attributed to having to sleep in his car on a recent trip back from the coast. There were no neurological symptoms and physical examination was largely unremarkable apart from paraspinal muscle spasm, so you managed him with simple measures.
Last week he attended the emergency department with the same pain and the discharge letter is attached. He was asked to see you if the pain persisted.
++
The following information is on his summary sheet:
++
Age
32
Past medical history
Hypertension
Gastro-oesophageal reflux
Alcohol abuse/dependence
Opiate dependence IV drug use
Dental caries/poor dentition
Medication
Telmisartan 40 mg mane
Esomeprazole 40 mg mane
Methadone syrup 5 mg/ml 3ml po per day
Paracetamol 500mg 2 qid prn
Allergies
Nil known
Immunisations
Up-to-date
Social history
Divorced—has shared custody of his three children
Smokes 20 cigarettes per day
Non-drinker
Family history
Hypertension
Osteoarthritis.
++
Below is the letter from the local emergency department.
++
++
++
This 32-year-old man was seen at the emergency department with back pain. He described three to four weeks of pain in the lumbar region which was not responding to conservative measures. Further history and physical examination were consistent with mechanical back pain and there were no red flags.
++
He was given oxycodone (Endone) tabs 5 mg 2 tds prn and meloxicam (Mobic) 15 mg daily and was referred for physiotherapy.
++
He has been instructed to return to see you if his symptoms do not resolve.
++
++
+++
INSTRUCTIONS FOR THE PATIENT, DOUGLAS SULLIVAN
++
You have now had almost five weeks of pretty constant upper lumbar pain, which you describe as deep and throbbing. If asked to score it, it is seven or eight out of ten. It started the day after you slept in your car returning from visiting your children on the coast. It’s worse with movement but also hurts when lying ...