What was causing this elderly male patient’s acute back pain?
Case of the month: In the latest in our series, Dr Andy Eaton asked what could be the diagnosis in this older male patient requesting stronger analgesia for acute back pain. Did you get the diagnosis? Answer revealed 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?
Answer: The turning point here comes with his response, when he says that the pain doesn’t really radiate anywhere, but that ‘both thighs feel like jelly … oh and it feels more like it’s bellyache going through to my back’.
The patient is advised to go back to A&E, where he is scanned and diagnosed with a large abdominal aortic aneurysm (AAA), which can be operated on before it ruptures.
Learning points
Most patients with an AAA are asymptomatic until the aneurysm is close to rupturing or leaking, and NICE tells us that we should always think about the possibility of a ruptured AAA in people with new abdominal and/or back pain. His leg symptoms should ring alarm bells as pain, weakness or numbness in the legs can be a sign of impending dissection. Of course, if the leg symptoms are bilateral or associated with changes to his usual bowel or bladder function, then cauda equina jumps to the top of your worry list.
The temptation in this case was to issue stronger analgesia without applying healthy scepticism around the original diagnosis (and fall into the trap of diagnosis momentum). But something didn’t sound right as he’d never consulted for mechanical back pain before. The key is to keep an open mind and revisit the diagnosis, rather than simply tweaking the treatment.
Dr Andy Eaton is a GP and GP Educator in Somerset
Sources and further reading
- O’Sullivan & Schofield. Cognitive bias in clinical medicine. J R Coll Physicians Edinb 2018;48:225–232
- NICE. Abdominal aortic aneurysm: diagnosis and management. [NG156] 19 March 2020
For more diagnostic puzzles, see previous articles in our Case of the month series:
- Case of the month answers: What was causing this patient’s nausea and tingling fingers? – Pulse Today
- Case of the month answers – what was causing this patient’s panic episodes? – Pulse Today
- Case of the month – answers: Did you get the cause of the patient’s sudden memory loss? – Pulse Today
- Case of the month answers: Did you get what caused this man’s pityriasis rosea? – Pulse Today
- Case of the month answers – what was the cause of this young worker’s abdominal pain? – Pulse Today
Have you handled a case which had a slightly surprising outcome? Perhaps an elderly man with non-vertigo dizziness? Or an unexpected cause of bradycardia? Would you like to share your case studies with us to help support and inform GPs? Please get in touch if you would like to contribute! [email protected]
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READERS' COMMENTS [1]
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Nice. Saw two cases of ruptured AAA in A&E during my GPST2 year. One was absolutely textbook renal colic, then the patient went into shock. The other was a man with groin pain with a longstanding inguinal hernia that felt soft – when I did a full and complete abdominal examination I could feel the expansile aorta! I don’t think I’ve seen one since (I might have missed one or two)