Case 1 | History

A previously fit and well 29 year old gentleman, John, presents to your clinic.

 

“Over the last 2 years I have been troubled by pain in my back and chest. I can’t remember hurting it but I did fracture a couple of ribs about 4 years ago, on the right side following a car accident. The injury settled down within a few weeks and has given me no problems since. I have never had any problems with my back before doctor. I’ve been up at the surgery a couple of times in the last 2 years and it was put down to wear and tear in the spine. Over the last few months I have been having a lot of problems with work and I’m worried that something serious might be causing it?”

 

It turns out he works as a brick layer. On further questioning he explains that the pain affects both his lower back and neck. It is worse in the morning but gradually improves as the day goes by, along with the stiffness - “ I get more work done after lunch!”

 

Pain is the predominant feature but his family and friends have noticed he has developed a stooped posture over the last year. The pain is not a problem at night but he admitted to have some pain in his chest if he lies prone on the bed.

 

Past medical history

 Fit and well

Attended the ophthalmologist on a couple of occasions with a painful red eye, but it cleared up completely.

 

Medications

Paracetamol

 

Systemic Review

- Chest:                     One chest infection within the last 12 months, cleared up with antibiotics from you.

- CVS:                        Nil

- GI:                           Nil

- Genitourinary          Nil

- Neurological            Nil

- Musculoskeletal      Some heel pain, again settled down with pain killers

 

Social

Non-smoker

No alcohol

Lives at home with wife and two daughters

Self-employed bricklayer

 

Family History

Older sister had problems with her lower back, not sure of any diagnosis