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INSTRUCTIONS FOR THE DOCTOR

This is a short case.

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.

Dear Doctor

Re: Mr Douglas Sullivan

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.

Kind regards,

Dr David Jones RMO

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 down. You ...

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