Yellow flag patients
Patient: 47-year-old nurse, divorced and lives alone. Involved in looking after mother with mild dementia/restrictive osteoarthritis.
Case
- Started after lifting at work, continued shift then had very sore next day. Took two days off work, immobile at home.
- Been back at work since, but is finding it increasingly painful, especially at the end of shift.
- Going straight to sofa/bed when gets home. Stiff in the mornings - lasting 20 minutes.
- Taking prn ibuprofen 400mg/ paracetamol 1g prn - some help.
- Feels unable to cope with work, asking for time off.
- Not enjoying work for last few years, stressful, not the job it used to be.
- Pmh - mild depression 7 years ago (during divorce), 1 episode of low back pain - 18 months ago - total 6 weeks off work.
Action
med3 - 1 week, add codeine 30-60mg qds/lactulose prn.
Review - 1 week
Not improving, codeine no real help. Worried that walking/bending is making her worse. Moving very stiffly on entering and leaving consultation room.
Action
Analgesia changed to tramadol 50-100mg qds. Advised to keep active. Referred to physiotherapy. Med 3-2 weeks.
Review - 2 weeks
Little change, tramadol small help, but is making her drowsy. Diclofenac 50mgs tds instead of ibuprofen, prn tramadol. Med 3-1 mmonth, due to see physio in 2 weeks, had some exercise sheets sent to her but is finding them too painful to do.
Review - 1 month
Seen physio once, shown some stretches and given some manipulation. Very painful next day, worried about going back again. Still feels unable to work. Managing short walks out of house, still looking after mum.
Review - 6 month
- Been seen at regular intervals - stopped going to physio as felt was aggravating pains. Pain now on and off throughout the day. Aggrevated by more than 15min of standing - but is manageable.
- Feels unable to go back to any work, Low level of activity. Mood low and is struggling financially as now on half pay. Involved in redundancy settlement at work.
- Learning points
- Reasonably long hx at presentation.
- Lots of yellow flags - hx of depression
passive coping - fear - avoidance
- not enjoying job
- Ideal candidate for eary referral to back specialist team - MDT approach-? Manipulation, psychological support of activity, acupuncture, early occupational health involvement.
Consequences of not returning to work have had a long tem influence on her. Poor prognosis of returning to active work.