Case 2 | History

Bill, a 41 year old male schoolteacher presents to your clinic.

He has a 5-month history of back pain radiating into her right leg.  This is on a background of long standing lower back pains over many years but this is the first time he has never had any symptoms in his legs.

Approximately 3 months ago he stooped over one morning and experienced a sudden onset of lower back pain that radiated into his right lower leg.  He has attended physiotherapy privately and despite persevering with exercises for 6 weeks his symptoms have continued.

He is now complaining of pain in his right buttock with pain radiating down the front of his lower leg into the anterior aspect of his right foot.  The back pain severity is 2-3/10 and the right leg pain is 9/10.  This is worse on stooping or sitting in upright positions for long periods of time.  It is only partially relieved by analgesia and lying in certain positions.

The left leg is unaffected and he has no bladder or bowel symptoms.

Over the last two weeks the pain has become much worse and he is now at the point of having difficulty walking.  He is now on sick leave from work but is very keen to get back as his final year students have their exams coming up soon.

 

Past Medical History

No history of malignancy

 

Medications

Tramadol 100mg QDS (for last 2 months)

Paracetamol 1g (for last 3 months)

 

No known drug allergies

 

Systemic Review

General            Keeping in general good health. No weight loss good appetite

Cardio               Nil

Respiratory       Nil

GI                      Nil

Neurological      Nil (as before no bowel or bladder symptoms).

GU                    Nil

 

Social

Lives at home with wife

Father of 3 children

Non-smoker

Social alcohol

 

Family History

None of note