Doctoring three – Patient Script for VBP – Low Back Pain
Case: Low Back Pain Description: Patient with low back pain has significant limitations in functional activities and ability to work
Patient Name: Louis McCleod Middle age person (40-60 yr old) is an airline pilot who has back pain
and radiating symptoms down the leg with sitting, getting his luggage in an out of the overhead bin, and in
home activities. Main Issues: Low back pain, cannot work without pain and numbness. Limitations in home and work
activities. Demographics: male age 40-60 years
Patient manner: patient in moderate to severe discomfort, moves frequently in chair, and ultimately asks if
it is okay if he stands because he is unable to sit for long periods of time. Chief complaint today: Low back pain, radiating symptoms. (“Feels funny down my right leg”)
Starting the interview: Upon greeting, the patient is cooperative, but appears distressed (due to pain and
exacerbation of symptoms in sitting position). History of present illness: The patient has low back pain that started two weeks ago when he/she was
moving furniture. The patient was moving furniture and felt a pop. Describes pain as a 8/10 in severity –
with peaks of 10/10 – or even 11/10. . Social history/lifestyle history - Married, lives with wife and 3 stepchildren (second marriage to
younger spouse) - ages 7, 5 and 2. Family history
Medical insurance – Blue cross/Blue Shield
Patient response to student findings (if part two is warranted)
Chief Complaint/Presenting Problem: Low Back Pain Setting:
_√ Clinic __ER
__Hospital
Type of Encounter: __√ New patient
__Other
__Follow-up
__Emergent
OPENING STATEMENT (SP to volunteer): “My back hurts – I think I ruptured a disk.”
When asked, patient responds that his age is 50 years old.
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PRESENT HISTORY OF SYMPTOMS: in patients’ own words
SYMPTOM #1: Onset:
“The pain started 2 weeks ago when my husband/wife and I were moving
furniture. I bent over to lift and felt a pop. I started taking Aleve and I thought I
would get better but I am no better now. At this point I cannot work.”
Location/quality:
“The pain is mostly across the lower back, both sides. If asked if it radiates: It
radiates down your right buttock, and down to the back and lateral side of your
lower leg and into the top of your foot. If asked what makes the back pain
worse: Bending over or trying to lift up anything by bending over makes it much
worse. Leaning forward, such as when you shave, makes it worse. Twisting
makes it worse. Sitting while leaning forward makes the back pain worse. Also,
when the back pain gets worse, you notice the radiation of the pain is much more
pronounced. If asked what makes it better: Lying down with your hips and
knees bent with a pillow under your knees helps relieve the pain. The Aleve helps
a little. Severity:
If asked to rate the pain on a scale of 1-10: “The pain is an 8/10 if you try to
bend over or after sitting for more than 10 minutes, and a 3/10 if you are lying with
your knees supported by a pillow. Sometimes the pain seems like a 10/10 – when
you bent over and ‘get a jolt.’”
Frequency: Except when you lay down with your knees supported with a pillow, it never goes
away.
What makes it better: Advil or Aleve, laying down (see above), and ice seemed to help. .
What makes it worse: Sitting and twisting or rotating
Associated symptoms: If asked if there is any weakness: You really cannot tell, because
anything you do hurts. You can still walk, but it just hurts.
If asked if there is any numbness or tingling: It is hard to say. Your leg feels
funny where the pain radiates, but you can still feel if you touch your leg in those
areas, but it feels “funny”, and duller compared to the other leg.
If asked about bladder or bowel problems: Able to urinate and move your
bowels OK, no changes from before.
I just really want to be pain free and be able to feel like a helpful part of my family.
PAST MEDICAL HISTORY: Two previous rounds of low back pain – both resolved after a few weeks.
History of allergies and asthma. PAST SURGICAL HISTORY: No prior surgeries
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CURRENT MEDICATIONS (OTC and routine): Aleve 1 to 2 2x a day as needed for pain. Antihistamines
as needed and uses Ventolin inhaler PRN. Patient states that he/she would like
to get stronger mediation for back but cannot take medication if flying, therefore is
“toughing it out.” “I cannot afford to have a drug test come back positive and I
need to work.” FAMILY HISTORY:
Parents: Both parents are deceased – Father (colon cancer at 65) mother (heart
problems at 75).
Siblings: Has a brother and sister – Brother has emphysema and sister has
diabetes. PATIENT VOLUNTEERS SOMETIME EARLY IN THE INTERVIEW: “What I am really worried about is
whether I am going to be able to keep working. I am out on sick leave right now because I cannot sit long
enough to fly a route, and I can’t lift more than about 10 pounds – so I can’t stow luggage. When I try to
get my luggage down, the pain almost brings me down to my knees. And forget about responding to
turbulence and sudden drops. My wife and I just built a big house as a "tax shelter" for income. I am
house-poor and living paycheck to paycheck. If I had to have surgery and be out, it would take 180 days
for my disability to kick in.” Is there anything you can do to help me with this horrible pain that does not
involve surgery? Is there a pain med that would not interfere with my ability to be a pilot?
If asked about functional limitations or limitations in activities and participation: Cannot sit long
enough to work or drive kids to school, cannot participate in helping with child-care, inability to participate
in exercise program (running). Also has difficulty getting in and out of chairs and toilet, picking up things
from floor, doing yardwork, and putting on pants and socks. (Cannot bend without pain – spouse wife is
helping – especially with socks). Meal preparation and housework also very difficult – especially leaning
over sink and vacuuming. The standardized patient may also mention that sexual intimacy is not possible
at this time – if desired. If asked if there are any other things that he/she cannot do but would like to do: “My wife thinks I
am totally worthless now. We usually share the childcare and I cannot change the diaper for 2 year old, I
can't put the 2 year old in car seat – the bend and turn is excruciating. I can’t even take the kids to and
from school/day care because I cannot sit that long.” Loves to garden and do yard work. HEALTH MAINTAINENCE AND PREVENTION
Medication Allergies: None known
Health Screening: (e.g. mammograms, colonoscopy, PSA) N/A Women:
<45 yrs old >45 yrs old
Exercise:
Before injury, regular in running.
Sleep:
Can only sleep for short periods on back with knees elevated or on side with
knee between before awakened by pain. Diet:
NA
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NA
Weight change:
Hobbies:
NA
None
Tobacco/Alcohol: Non-smoker-quit smoking 10 years ago, used to smoke half pack a day for 20
years before that, social drinker
Sexual Activity:
Limited by back injury currently
SOCIAL HISTORY Occupation:
hard worker.
Airline pilot- has worked for same airline for 20 + years. They know he is a
Marital status:
Married
Children:
3 children – 7 (boy), 5 (girl), 2 (boy) Life Stressors:
Worried about work, family, children, and finances. His wife does have family
in the area that can help with the children, so maybe they could help her during this time. Does have a
good church that may be able to help if money gets tight.
REVIEW OF SYSTEMS N/A
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