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Patient Data

Past Medical History

Hypertension
Hypercholesterolaemia
Osteoarthritis of Left knee and both wrists

Drug and Allergy History

Amlodipine 10mg OD
Atorvastatin 20mg OD
Co-dydramol 10/500mg - 2 Tabs up to 4 times daily for pain when needed

Recent Notes/Consultation

Seen by first contact Physiotherapist- Carl Beveridge (Physiotherapy access role) 5 weeks ago due to back pain

Reports back pain ongoing for 1 week. No red flags, likely musculoskeletal. Analgesia-can try ibuprofen gel and back exercises. Safety netted and advised to Recontact if worsening

Seen 2 weeks ago by Dr Daniel Stubbs (Clinical practitioner access role)

Recurrent back pain, waking patient up at night, weight loss and feeling tired. Plan: continue Analgesia, request bloods and review afterwards

Bloods done

U+E and Bone Profile-Normal, FBC as below:

Reason for Consultation: Patient booked appointment to discuss blood test results

Blood Test Results

TestResultReference Range

HB (Hemoglobin)90 g/L ⚠130 - 180 g/L

Mean Cell Volume (MCV)84 fL80 - 100 fL

WCC (White Cell Count)3.1 x 10^9/L ⚠3.6 - 11.0 x 10^9/L

Platelet Count100 x 10^9/L ⚠140 - 400 x 10^9/L

CRP (C-Reactive Protein)80 mg/L ⚠<7 mg/L

Plasma Viscosity6.8 mPa/s ⚠1.50 - 1.72 mPa/s

Blood tests reviewed — see table

Patient Story (Role Player's Brief)

You are Thomas, a 75-year-old retired pilot. You are here to discuss your blood test results You did this blood test because you reported to the GP about having a back pain for over 6 weeks now, it wakes you up at night.

You have used co-dydramol and ibuprofen gel, but it was not working.

You decided to get over the counter ibuprofen to use, this helps slightly but it also gives you reflux symptoms, so you will want some tablets to address the reflux.

You have lost weight despite not changing your diet or doing any exercise. You feel tired all the time.

Social History: You live alone, non-smoker, no alcohol. You are a retired Pilot

Idea: You wonder if this is chronic back pain due to your prolonged sitting down for long haul flight while you were a pilot

Concerns: you are losing weight and feeling tired this is beginning to affect you

Expectations: You want the GP to tell you about the results

Accept anything the doctor offers

React with visible shock and disbelief when the doctor mentions a diagnosis of cancer, pause, take a moment to process, and respond with a mix of concern, fear, and confusion.

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

Management

Arrange an urgent urine test for Bence Jones protein and a blood test for serum protein electrophoresis to check for signs of myeloma.
Explain to the patient that if these results come back positive, an urgent referral will be made to a haematologist under the 2-week suspected cancer pathway for further assessment. The specialist may arrange additional investigations and, if necessary, discuss the case at a multidisciplinary team meeting involving 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.
Also advise to look out for symptoms of high calcium levels like thirst, constipation, or increased urination.
Inform the patient that if he has not heard from the GP practice or the hospital within two weeks, he should contact the surgery to follow up.
Safety net: Advise the patient to seek immediate medical attention if he develops symptoms such as numbness in the perianal area, difficulty passing urine or controlling their bowels, or sudden weakness in the legs as these could be signs of cauda equina syndrome, a medical emergency.

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 am 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 emphasise 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.

Learning Points 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.

Back Pain With Abnormal Blood Test