Case 5 | History

32-year-old police officer presents with lower back pain.

He was previously fit and well and only recently got married.

Over the last few weeks he has been moving house and 2 days ago he was bending over to pick up a box and experienced a sudden pain in his lower back.  He had to stop what he was doing and lie down on the floor.  He took some anti-inflammatory and the pain gradually subsided.

He presents now two days later looking for a sick-note as he is unable to go back to work due to the pain.

The pain is localized to the lower left side of his back.  It is worse on movement and relived when he rests, particularly when he lies flat on the bed.  It has intermittently radiated into his buttock and hamstrings but no further down his leg.

His bladder and bowels are working normally and has no symptoms in his right leg. 

 

Past Medical History

No previous problems.

 

Medications

Ibuprofen 400mg TDS.

No known drug allergies.

 

Systemic Review

General               - Nil.

Cardio                 - Nil.

Respiratory         - Nil.

GI                        - Nil.

Neurological        - Shooting pain into left buttock and back of this thigh.

GU                       - Nil.

 

Social

Recently married, no children.  Previously very fit and active but recently less so.

Non-smoker.

No alcohol.

 

Family History

None of note.