Patient Instructions — KAI SILVA
Kai Silva, 49 years old (30/01/1977).
Your opening statement is:
‘I’m really worried, my back is really painful and things don’t feel right ‘down below’. It all started 2 weeks ago when I was lifting my son from his wheelchair to his bed, I got this sudden severe pain in my back. I saw my GP last week who gave me pain killers which helped a little but they told me that if I felt any numbness to come straight to A&E.’
Today
You have come to the Emergency Department today as the pain is worse (9/10). It is a pressure like pain in the lower back you have a shooting type pain going down the back of both legs. This worries you because before it was only in the right leg. It does not feel normal when you are sitting down, feels numb in the genital and anal area, you have not been able to pass urine this morning, no bowel incontinence. Your legs feel weaker than usual - you struggled to get up the steps this morning and you feel unsteady when you walk. You have not done anything that you think could have made this worse. Now nothing is making the pain better, since this morning the pain is there all the time, movement makes it much worse.
No weight loss.
No fevers, no night sweats.
No stomach problems, no nausea or vomiting.
No headaches, no visual changes.
Initial Pain details
Site – lower back and right leg.
Quality – sharp, shooting, severe.
Intensity – pain level 7/10.
Timing – 2 weeks, following trying to lift disabled son out of bed. Son is a teenager and weighs around 40kg. You were rushing and had not had time to use the hoist.
Aggravating factors – movement, walking.
Relieving factors - you saw your GP last week who advised to take painkillers, keep moving and they referred you to physiotherapy. The paracetamol and ibuprofen helped with the pain (improved to 3/10 pain score) and you were able to get around the house. You remembered the GP said to get help straight away if you had any numbness ‘down below.’
Secondary symptoms - some numbness in the foot from the outside ankle (lateral malleolus) through to the little toe. Over the last two weeks there has been no numbness or changes to sensation or weakness of the legs, no pins and needles, no changes in sensation of the genital/ saddle area, you had been passing urine normally and no issues with your bowels.
PMHX - episode of back pain 3 years ago, diagnosed as sciatica by GP. But no issues between then and now.
Meds - no regular medications, currently taking Paracetamol 1g four times a day and ibuprofen400mg three times a day
Allergies - no known drug allergies.
FHX - mum had back problems all her life but not sure what her diagnosis was.
Social Hx - lives with disabled son, no carers, partner no longer living with them.
Does not work as looks after son - full time carer.
Non-smoker, no alcohol, no illegal drugs.
ICE
Ideas - slipped disc.
Concerns - not able to care for son. Worried as you are the main carer, you don’t get any outside help so worries about how you are going to cope at home.
Expectations - to have a scan and for some extra pain killers and be able to get home to son.
Your demeanour is friendly and approachable, but you are agitated and nervous about what these new symptoms mean. You have a good understanding about health and readily offer information, but please be very succinct as the students only have 6 minutes for this.