What is the underlying cause of this elderly male’s acute back pain?
Case of the month: Continuing our series, Dr Andy Eaton asks what could be the diagnosis in this older male patient requesting stronger analgesia for acute back pain. Post your answers in the comments below!
Details of the case have been changed to ensure anonymity
A 67-year-old semi-retired farmer contacts the practice on a Monday morning with an urgent prescription request. He says he was seen in the local A&E the previous night, and given some codeine 15mg for a back sprain. He is now requesting something stronger, as the pain is stopping him from working on the farm this morning.
Your receptionist rightly adds him to the duty list for a callback. You phone him within the hour, and as a typical farmer, it seems he is playing down his symptoms. He tells you that in the last 24 hours, he has taken four doses of codeine 30mg (2 x 15mg) with paracetamol 1g each time, and that he just wants something to get him through the day today after which he promises he will rest up.
You see from his records that he smoked 15 cigarettes a day until around 6 years ago when his first grandchild was born, and he is on ramipril and amlodipine for hypertension.
You take what he says at face value, but you can’t help thinking it’s a bit odd, as he has never consulted regarding his back before, and apart from being as active as usual on the farm, there is no history of recent trauma. He tells you that his bowels and waterworks are fine and haven’t changed recently, and he has felt a bit tired lately but is not unwell in himself.
You are wondering whether to issue him the script with clear safety netting advice, or whether to invite him into the practice first for a face-to-face (assuming he agrees). One of your GP colleagues has phoned in sick this morning, which makes you even more short of on the day appointments than usual, but you are trying not to be swayed by this.
You then ask him if the pain radiates anywhere, maybe to his legs, and his answer makes the hairs on the back of your neck tingle.
‘It’s funny you ask that Doc because…’
What is he about to tell you? What could be the underlying cause? Share your ideas in the comments box below. Answer to be revealed soon!
Dr Andy Eaton is a GP and GP Educator in Somerset
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READERS' COMMENTS [6]
Please note, only GPs are permitted to add comments to articles
Waking at night with pain? Weight loss? Pain radiating down leg? Cauda equine symptoms?
Metastatic bone pain?
Abdominal aortic aneurysm is my bet
AAA
I would certainly be concerned about possibility of serious conditions including acute lumber disc prolapse or even possible beginning of cauda equina syndrome or myeloma, spinal lymphoma or spinal Metastasis. I would like to see him face to face urgently.
As a hypertensive smoker with acute back pain, assuming radiation down both legs, this does indeed suggest ruptured AA, (though I’m surprised he’s still alive).
If the pain is upper back (it does not state lower back) radiating down an upper limb (again it does not state lower limb) then a Pancoast lung tumour could explain his pain/tiredness without respiratory symptoms , especially in a smoker..
I would ask this patient to come in for urgent physical examination. I should check reflexes and pheripheric pulses in both legs and do a rectal examination to check on anal sphincter tone .Check blood pressure .Confirm there is no constipation or urine incontinence .
I will be thinking on cauda equina syndrome , sleep disc, metastatic disease from lungs or prostate and also consider possibility of AAA.