Elderly Man Has Back Pain Which Is Keeping Him Awake At Night — Free SCA Practice Case

Character Overview: You are Arthur. You are 72, fiercely independent, and live alone since your wife, Mary, passed away in a care home. You love your garden; it is your pride and joy. Over the last six weeks, you have developed a deep, gnawing pain in your lower-to-mid back. Crucially, the pain is worse when you lie down. You have been waking up in the early hours in agony and having to pace the hallway to get any relief. You are also feeling generally exhausted and your appetite has shrunk, but you attribute this to the lack of sleep. You have been passing urine more frequently at night, with a poor stream, but you assume this is "just what happens to old men." You are terrified that your spine is "crumbling" from old age, and your greatest, hidden fear is that you will lose your mobility, lose your house, and end up dying in a care home like Mary. You will not volunteer your urinary symptoms or your fear of the care home unless the doctor specifically asks about your waterworks or explores your underlying worries about the future.

Consultation Flow & Responses:

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  The Opening

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  If the doctor asks an open question: "Good morning, Doctor. I wouldn't normally bother you, but I need some stronger painkillers for my back. The paracetamol isn't touching it, and it's got to the point where I can't even sleep. I just need something to get me back out in the garden."

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  Data Gathering

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  The Mechanical vs. Inflammatory/Malignant Pain (The Red Flag):

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  "It's in the middle-to-lower part of my back. It's a deep, constant, boring ache."

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  "It actually feels worse when I lie flat in bed. I can't get comfortable. I end up getting out of bed in the early hours to walk around the living room because the pain is so bad."

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  "No, I haven't done any heavy lifting or had a fall."

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  Systemic Screen & Cauda Equina (Neurological):

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  "I haven't been eating much lately. My trousers are definitely a bit looser, I've had to tighten my belt a notch." (Weight loss).

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  "No, I haven't felt feverish."

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  "No numbness between my legs, and I can control my bowels perfectly fine." (Rules out Cauda Equina).

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  The Urological Clue (Prostate):

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  If asked about passing urine: "Well, I am up three or four times a night to go to the toilet. And it takes a good minute to get the flow started. But I'm 72, Doctor, all my mates at the bowling club have the same problem. That's just age, isn't it?"

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  ICE & The Core Revelation (The Hidden Fear) - ONLY REVEAL IF ASKED:

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  If the doctor asks: "What are you worried is causing this?" or "How is this impacting your life?"

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  Reaction (The Reveal): You look down, kneading your hands. "I'm worried my spine is crumbling away. My wife, Mary, lost her mobility and we had to put her in a care home. She hated it there, and she faded away. If my back goes and I can't manage the house or the garden... I can't go into a home, Doctor. I'd rather drop dead in my greenhouse. Please, just give me something strong to keep me moving."

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ICE — Ideas, Concerns, Expectations

Actor guidance: Do not volunteer any of the following unprompted. These responses surface only when the candidate directly explores the patient's perspective through open or targeted questioning.

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  Ideas: Arthur believes his spine is "crumbling" or wearing away due to old age and years of physical work in the garden. He has no suspicion of anything more sinister — he sees this as a mechanical problem of getting old and assumes he just needs stronger painkillers to push through it.

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  Concerns: His deepest fear — which he will only share if the doctor genuinely explores his worries — is that he will lose his mobility, be unable to manage the house and garden, and end up dying in a care home the way Mary did. He is also privately worried that the exhaustion and weight loss mean he is "fading," but he rationalises this as poor sleep rather than confronting it.

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  Expectations: Arthur wants stronger painkillers so he can sleep through the night and get back to his garden. He is not expecting investigations or referrals — he came for a prescription and to be sent on his way. He will need careful handling if the doctor suggests something more involved.

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If Asked — Medical History and Medications

Actor guidance: Respond naturally if the candidate asks about your medical history, medications, or previous visits. Do not volunteer this information unprompted.

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  If asked about blood pressure / hypertension: "Yes, I take a tablet for my blood pressure — one a day, the amlodipine. I've been on that for years. I take it every morning with my tea, no bother. I've never had any problems with it."

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  If asked about the osteoarthritis / knee problems: "My knees have been stiff for years — they creak when I get up from my chair. But it's nothing like this back pain. The knees I can live with. This is something different entirely."

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  If asked about paracetamol use: "I take a couple most days now for the back, but they don't make a blind bit of difference. I used to just take the odd one for my knees if they were playing up, but this back pain is on another level."

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  If asked about allergies: "No, no allergies to anything that I know of."

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  If asked when he last saw a doctor / why he hasn't been to the surgery: "I haven't been in... must be two or three years now. After Mary passed, I just didn't see the point in coming. I was managing fine on my own. It's only because this back has got so bad that I've come in today."

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  If asked about previous blood tests: "I think they did some routine bloods a few years back and everything was fine. That was before Mary went downhill, though. I haven't had anything checked since."

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Social History and Lifestyle Impact

Actor guidance: This information can be shared naturally during conversation, particularly when the doctor asks about daily life, how the pain is affecting you, or what your days look like.

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  Occupation and daily life: Arthur is retired. He spent most of his working life as a maintenance engineer at a local factory before retiring at 65. His days now revolve around his garden, which he tends to daily — pruning, weeding, mowing the lawn. He also walks to the bowling club twice a week. He lives alone in the house he shared with Mary and manages all his own cooking, cleaning, and shopping. He has a son, David, who lives about an hour away and visits every couple of weeks, but Arthur is fiercely private about his health and has not told David about the back pain.

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  Lifestyle impact of the condition: "I used to be out in the garden by half seven every morning. Now I can't even bend down to pull a weed without this pain seizing up my back. I tried to dig over the vegetable patch last week and I had to stop after ten minutes — I was nearly in tears. And I haven't been to bowls in three weeks because I can't do the bending to deliver. The garden's getting away from me, Doctor, and that's the one thing I've still got."

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  If asked about sleep in more detail: "I get into bed and the pain just builds. Later in the night I'm walking up and down the hallway in the dark. I might doze off in my armchair for an hour or two before it gets light, but that's not proper sleep, is it? I'm shattered all day."

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  If asked about alcohol: "I have a whisky in the evening — just the one, sometimes two at the weekend. Nothing excessive. I've always been moderate."

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  If asked about smoking: "I gave up years ago — must be over twenty years now. I smoked a pipe for a while when I was younger, maybe fifteen years or so, but I knocked it on the head when Mary asked me to."

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If Asked — Associated Symptoms

Actor guidance: Do not volunteer any of the following. Respond only if the candidate specifically asks about these symptoms.

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  If asked about pain anywhere else in the bones or joints (other than knees): "No, it's just the back. My knees are the usual stiffness but that's nothing new. I haven't had pain in my hips or ribs or anywhere else."

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  If asked about leg weakness or difficulty walking: "My legs feel all right in themselves — they're not weak or giving way. It's the back pain that slows me down, not my legs."

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  If asked about pins and needles or tingling in the legs: "No, nothing like that. No tingling or funny feelings."

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  If asked about changes in bowel habit: "No, my bowels are regular enough. No blood or anything like that."

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  If asked about blood in the urine: "No, no blood. It's just the slow stream and getting up all the time at night."

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  If asked about difficulty starting or stopping urination, or dribbling: "It does take a while to get going, and sometimes it feels like I haven't quite finished. But I put that down to age."

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  If asked about bone pain that is worse at night specifically: "Yes, it's definitely worse at night. During the day if I keep moving it's bearable, but the moment I lie down it really starts."

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  If asked about shortness of breath or cough: "No, I'm not short of breath. No cough either."

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  If asked about chest pain: "No, nothing like that."

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  If asked about fatigue or tiredness beyond the sleep issue: "I suppose I am more tired than I used to be, even during the day. I put it down to not sleeping, but even when I do sit down I feel drained. I don't have the energy I used to."

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  If asked about mood or how he is coping emotionally: "I'm managing. Some days are harder than others. It's been lonely since Mary went, but I keep busy with the garden. Or I did, until this back started."

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Negotiation & Collaborative Management Plan

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  If the Doctor just diagnoses mechanical back pain and prescribes Naproxen/Codeine:

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  Reaction: "Thank you, Doctor. I'll pick those up today." (Note: Candidate critically fails for ignoring multiple red flags — night pain, weight loss, age — and missing a likely spinal metastasis).

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  If the Doctor says "I need to examine your prostate (do a rectal exam)":

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  Reaction: Confused and resistant. "My prostate? Doctor, it's my back that's killing me, not my bottom! Why on earth do you need to do that?" (Testing the doctor's ability to explain the anatomical/pathological link between prostate cancer and spinal bones).

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  If the Doctor uses the word "Cancer" bluntly without warning:

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  Reaction: Shocked and panicked. "Cancer?! You think it's cancer? In my spine? Am I going to end up paralysed?"

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  If the Doctor explains the need for urgent bloods (PSA) and an MRI scan:

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  Reaction: "An MRI scanner? How long will that take? Will you give me something for the pain in the meantime? Because I really can't sleep."

Safety Netting / Follow-up

• ●If the Doctor warns you about signs of spinal cord compression (weakness in legs, losing bladder control):
• ●Reaction: "Right. So if my legs go weak or I wet myself, I don't wait for the scan, I call 999. I understand."