This post is aimed at professional practitioners. This is not for diagnosis, and is for informational purposes only. This was a real case , but has been anonymised for the retelling.

The idea of these is to reflect on what went well, what could have been done better and ultimately, how to improve practice.

Context – Pre Covid, so no prior teleconsultation.

A 72 year old female presented to the clinic with lower back pain. This had been present for a few months, on and off, but had got worse when she was pushing a chest of drawers across a room to clean behind it. Otherwise fit and well, she lived alone with 2 cats. A case history was taken, as well as general medical history.

The presenting complaint, a low back ache, had started some time ago, which she put down to the natural processes of aging and, as it relieved with over the counter analgesia, had not sought further advice. When pushing the furniture, she felt something “go” and as it hadn’t resolved with rest and painkillers, she sought help. It rated 8 out of 10 on a pain scale, easing to 4-5 out of 10 with certain positions but was not improving.

Her BMI was within healthy range, she had no preganacies, no smoking history, moderate alcohol intake and was active in the local community.

Her medical history was significant only for a well controlled haematological presentation (essential thrombocythemia – ET) for which she was regularly reviewed by the local hospital. Her only medication was hydroxycarbamide for this, and over the counter nutritional supplements from the health food store. Family history was of a sister who was being investigated for bowel polyps, a father who died of leukemia age 80 and a mother who passed away with a stroke.

Red flags (fatigue, weight loss, night sweats, unremiting pain, fevers, respiratory changes, unexpailned bruising, bowel and bladder changes) were negative, as were the 6 domains (cardiovascular, respiratory, gynaecological / urinary tract, gastrointestinal, musculoskeletal, and neurological). She noted that she had had a few episodes of loose stool, which were ongoing and darker than usual.

Examination indicated a restricted left sacroilliac joint, with point tenderness over this area and no other significant findings. There were no clinical findings of note.

A relieving position was found on the couch, where compression of the sacrum provided temporary relief.

However, on refection it was not possible to create a satisfying working diagnosis and to isolate the pain to a purely musculoskeletal cause, especially given the bowel changes. As such, I referred her back to her GP with a note, and without fee or intervention. (I will not charge if I do not treat due to medical concerns).

The rest of this case is from third parties, as the lady did not present again.

After a teleconsultation, the GP referred the patient to the emergency same day care unit at her local hospital. Here, blood tests indicated that her platelet count was very low and she was admitted for further investigation and medical management. She sadly passed away a week later, as her ET had flipped to an acute form of leukemia.

Lessons learned:

1. The presentation looked like a lower back pain, with no significant clues that there was an underlying pathology. In this case, I suspect that it was acute back pain, on top of pathological changes from the medical presentation.
2. I need to learn more about common medications, and be willing to check the BNF if I am unsure.
3. This was only caught as I have a strict set of protocols and am naturally cautious. If she had been a more assertive character, or I was tired, I may have missed certain elements and may have treated inappropriatley.