Thomas Hansford

Age: 75 years old male

Examiner

Station List
Doctor
Patient
Full Case

Marking Scheme

Data Gathering and Diagnosis   

  • Ask about the nature of the back pain (location, character, severity).
  • Ask if the pain radiates to other areas (e.g. legs).
  • Ask whether the pain is worsening, improving, or remaining unchanged over time.
  • Ask if the pain disturbs sleep or wakes the patient at night.
  • Ask about any weakness, numbness, or tingling in the legs.
  • Ask if the patient has normal control of bladder and bowel function (to rule out spinal cord compression).
  • Ask about unintentional weight loss.
  • Ask about fever or night sweats.
  • Ask about loss of appetite, fatigue, or general feeling of being unwell.
  • Ask about symptoms of hypercalcaemia, such as: Abdominal pain, constipation, excessive thirst or urination, muscle weakness, confusion or drowsiness
  • Ask about family history of cancer, blood disorders, or other relevant conditions.
  • Ask about Anaemia red flags (headache, dizziness, palpitations, SOB, chest pain etc)  
  • Ask how the patient is coping at home physically and emotionally
  • Ask about social lifestyle- smoking, alcohol etc. 
  • Break bad news – Give diagnosis of multiple myeloma

Example of explanation to patient

Tom, while long term (chronic) back pain can be responsible for your back pain; I have to share with you that your symptoms are pointing to something that could be more serious.

The combination of your back pain waking you up at night, the fatigue, the weight loss, and your raised inflammatory markers on your blood test are concerning.

 Based on these signs, I’m worried that there may be a possibility of multiple myeloma, a type of cancer that affects the bone marrow. The bone marrow is the soft, spongy tissue found inside your bones that helps in production of blood cells. It’s like the body’s blood cell factory. 

I understand this news is very upsetting, and I want to emphasize that we don’t have a definitive diagnosis yet. We will need to run additional tests, such as blood tests, urine test and refer you to a specialist very urgently to get a clearer picture of what’s going on.

Now, if you haven’t heard from us or a specialist within 2 weeks, it’s really important that you call the surgery so we can chase that up , we’ll make sure you don’t get lost in the system.

Also, if at any point you notice new symptoms such as difficulty controlling your bladder or bowel, numbness around your bottom or genitals, or sudden weakness in your legs, those could be signs of a rare but serious condition called cauda equina syndrome. If that happens, go straight to A&E or call 999 — don’t wait.

Management

  • Arrange an urgent urine test for Bence Jones protein and a blood test for serum protein electrophoresis to check for signs of myeloma.
  • If these tests show abnormal results, refer the patient urgently to a haematologist (blood specialist) under the 2-week suspected cancer pathway for further evaluation. The specialist may arrange additional investigations and, if needed, discuss the case in a multi-disciplinary team (MDT) meeting that includes cancer specialists.
  • Arrange an urgent X-ray of the lower back to look for any signs of bone damage or fracture.
  • If offering an NSAID for pain relief, prescribe a PPI (like omeprazole) to protect the stomach lining.
  • Follow up in 2 days to review the results and check on the patient’s symptoms.
  • Safety netting: Advise the patient to seek immediate medical attention if they develop symptoms such as numbness in the perianal area, difficulty passing urine or controlling their bowels, or sudden weakness in the legs — these could be signs of cauda equina syndrome, a medical emergency.
  • Also advise to look out for symptoms of high calcium levels like thirst, constipation, or increased urination.
  • If the patient hasn’t heard from the GP practice or the hospital within 2 weeks, they should contact the surgery to follow up.

Learning point from this station: ​

In patients presenting with persistent back pain, particularly when associated with red flag symptoms such as night pain, unexplained weight loss, fatigue, or raised inflammatory markers, clinicians must maintain a high index of suspicion for serious underlying conditions like multiple myeloma.

Multiple myeloma is a cancer of the bone marrow, which can cause bone pain (often in the spine), fatigue, and other systemic features. It can lead to pathological fractures, hypercalcaemia, anaemia, and renal dysfunction. Investigations such as serum protein electrophoresis, urine Bence-Jones protein, and urgent imaging play a crucial role in early identification.

X-rays of the lumbosacral spine are not routinely recommended in primary care for non-specific back pain as they rarely change management and expose patients to unnecessary radiation. 

However, spinal X-rays should be considered when there is clinical suspicion of serious pathology, such as malignancy or compression fractures, which may be present in conditions like multiple myeloma.