Case 3 | History

74 year old, Thomas, attends your clinic with back pain.

Thomas is well known to you as he previously had treatment for prostatic carcinoma 5 years previously.

His main complaint is pain in the middle of his back.  It has been present for approximately 2 months and has not improved despite pain killers.

The pain is localised with no radiation into the legs.  It is present all day and is not associated with movement.  It gives him, and his wife considerable trouble at night, as he finds it increasingly difficult to get off to sleep with the pain.

Over the last number of days he explains that his legs are feeling slightly heavy and feels he is more clumsy arounf the house.  He has tripped and fallen a couple of times, most recently this morning on the doorstep.

On further questioning there has been no change in his bladder control, but this has been troublesome since his radiotherapy.  He had no problems with bowel control.

 

Past Medical History

Prostate Carcinoma

-       Radiotherapy in 2004

-       Follow-up with Mr Little 12 months ago.

-       PSA has remained low and the most recent level was 4.2.

 

Medications

Zoladex  (1 subcutaneous injection every 12 weeks)

Finasteride 5mg / day

Calcichew D3 Forte

Paracetamol 1g QDS

 

No known drug allergies

 

Systemic Review

General              - Nil

Cardio                - Nil

Respiratory        - Nil

GI                      - Nil

Neurological       - Feels lower legs are unco-ordinated and tire easily.

GU                     - Long standing poor stream and hesitancy following radiotherapy

                           - Passing urine less and feels he is not emptying his bladder fully, but again ths has been a problem in the past. 

 

Social

Lives at home with wife

Non-smoker

No alcohol

 

Family History

None of note