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From the case files:

Back with back pain

01 January 2013

Mrs S was a 35-year-old shopkeeper with an established history of recurrent UTIs, which had responded well to antibiotics. An ultrasound in the past had confirmed kidney stones.

She presented to her GP, Dr F, complaining of back pain for the past six weeks and tingling in her right leg, which was relieved by lying down. Dr F took a full history and examined her back, including a neurological examination. Dr F diagnosed Mrs S as having sciatica, exacerbated by lifting heavy boxes in the shop. Dr F prescribed regular analgesia and advised her about careful lifting and gentle exercises. However, the pain continued to worsen.

Dr F saw her again four weeks later and this time was concerned as Mrs S was having difficulty walking. She was referred for physiotherapy. Whilst waiting for the physiotherapy appointment Dr F saw Mrs S again, this time with symptoms of a urinary tract infection including frequency and urge incontinence. Again a urine sample was sent to the lab and confirmed a urinary tract infection, which was treated successfully with antibiotics.

Mrs S’s back pain and right leg sciatica continued to deteriorate to the extent that she could not sit and she returned to the surgery again. Dr F was concerned about the repeated urine infections in association with back pain and the recent onset of incontinence, and informed Mrs S that she felt an ultrasound scan of her urinary tract system would be prudent. A urology referral was made and a CT scan confirmed a renal stone and a retroperitoneal mass.

Mrs S had further investigations for the mass and was eventually diagnosed with non-Hodgkins lymphoma. Mrs S was very upset when she was diagnosed, as she felt the back pain had always been due to the mass, and she made a claim against Dr F for failing to refer her earlier. Experts who looked into the case agreed that the management had been appropriate and Dr F had acted like any other reasonable GP would have at the time.

The experts also found that although some of the examinations weren’t examples of best practice, they were not below an unacceptable level. At no time was an urgent or emergency referral warranted. The case was discontinued after a detailed letter of response was sent.

Learning points

  • Back pain is one of the commonest complaints seen in general practice. Doctors may easily disregard back pain but it is important to keep in mind that a small proportion of them mean serious or life-threatening pathologies.
  • Taking a good history and examining the patient regularly when they attend without a firm diagnosis with back pain is important, even if they come with a recurrent complaint. Re-examine if there is any change in symptoms. Good documentation of history and examination is safe practice. This helps other clinicians to understand the history of a complaint better. It can be the basis of a good defence if a case ever becomes a claim.
  • When patients attend with different symptoms and illnesses at the same consultation, differential diagnosis can be more complex and therefore greater awareness is necessary.
  • Keep up-to-date with guidelines on best practice for back pain. [See NICE guidelines for low back pain. This covers management of musculoskeletal back pain but not malignancy, infection, fracture and inflammatory conditions such as ankylosing spondylitis.] Remember these alternative differential diagnoses when assessing a person with back pain.
  • Failure to diagnose is not inevitably negligent. There was a careful, well-documented assessment of the patient on every occasion.
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