Case 4 | History

41-year-old accountant, Jason presents to your emergency out of hours clinic with acute lower back and leg pain.

You know him well as he has seen you before with sciatica last year, which resolved and he made it back to work within 2 weeks.

He explains that during his work yesterday he stooped over and immediately experienced lower back pain.  It radiated into his right leg but by the time he made it home the pain was radiating into both legs.

He took his normal analgesia, which improved his back pain but the pain in both his legs has increased and now presents to your clinic for stronger pain relief.

This is the first time he has experienced the pain into both legs at the same time.  On further questioning he feels both soles of his feet are tingling and painful to walk on.  He hasn’t passed urine since early this morning but he reluctantly explains that he lost control of his bladder once.  Again, he hasn’t passed stool and is unaware of any altered sensation around the back passage.

 

Past Medical History

Mechanical back pain – well controlled with analgesia and has responded to physio in the past.

 

Medications

Co-codamol 8/500 when required.

 

No known drug allergies.

 

Systemic Review

General                       - Nil

Cardio                         - Nil

Respiratory                 - Nil

GI                                - Nil

Neurological               - Altered sensation bilateral soles of feet and ankles.

GU                              - Loss of bladder control on one occasion.  Has not passed urine since yesterday.

 

Social

Young family, 3 children aged 1, 3 & 6.

Non-smoker.

Social alcohol.

 

Family History

None of note.