Cases/Musculoskeletal Health

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

Elderly man has back pain which is keeping him awake at night

Station Timer

12:00

Golden Minute

Initial Introduction

•Introduce yourself

•Ask an open question — "How can I help you today?"

•Listen — don't interrupt

•Catch early cues

Data Gathering

History, ICE & Diagnosis

Clinical Management

Diagnosis, Plan & Decisions

Safety Net

Follow-up & Close

12:00

Golden Minute

Materials for Candidate

Please review before starting the consultation

Patient Profile

Full Name

Arthur Pendelton

Age

72 years

Consultation Type

Video

Age

72 (DOB: 08/02/1954)

Situation

Face-to-Face Consultation.

Reason for Encounter

"Patient is complaining of a bad back that has been bothering him for the last 6 weeks. Says it is keeping him awake at night."

Medical Records

●PMH: Hypertension, Osteoarthritis (Knees).
●Medications: Amlodipine 5mg OD, Paracetamol PRN.
●Allergies: NKDA.

Recent Notes

●3 years ago: Routine bloods normal. Has not attended the surgery since his wife passed away two years ago.

Patient Script

For the friend playing the patient role

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 at 3 AM 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:

●
The Opening
●
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."
●
Data Gathering
●
The Mechanical vs. Inflammatory/Malignant Pain (The Red Flag):
●
"It's in the middle-to-lower part of my back. It's a deep, constant, boring ache."
●
"It actually feels worse when I lie flat in bed. I can't get comfortable. I end up getting out of bed at 3 AM to walk around the living room because the pain is so bad."
●
"No, I haven't done any heavy lifting or had a fall."
●
Systemic Screen & Cauda Equina (Neurological):
●
"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).
●
"No, I haven't felt feverish."
●
"No numbness between my legs, and I can control my bowels perfectly fine." (Rules out Cauda Equina).
●
The Urological Clue (Prostate):
●
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?"
●
ICE & The Core Revelation (The Hidden Fear) - ONLY REVEAL IF ASKED:
●
If the doctor asks: "What are you worried is causing this?" or "How is this impacting your life?"
●
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."

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.

●
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.
●
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.
●
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.

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.

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

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.

●
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.
●
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."
●
If asked about sleep in more detail: "I get into bed and the pain just builds. By 3 AM I'm walking up and down the hallway in the dark. I might doze off in my armchair for an hour or two around five, but that's not proper sleep, is it? I'm shattered all day."
●
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."
●
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."

If Asked — Associated Symptoms

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

●
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."
●
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."
●
If asked about pins and needles or tingling in the legs: "No, nothing like that. No tingling or funny feelings."
●
If asked about changes in bowel habit: "No, my bowels are regular enough. No blood or anything like that."
●
If asked about blood in the urine: "No, no blood. It's just the slow stream and getting up all the time at night."
●
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."
●
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."
●
If asked about shortness of breath or cough: "No, I'm not short of breath. No cough either."
●
If asked about chest pain: "No, nothing like that."
●
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."
●
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."

Negotiation & Collaborative Management Plan

●
If the Doctor just diagnoses mechanical back pain and prescribes Naproxen/Codeine:
●
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).
●
If the Doctor says "I need to examine your prostate (do a rectal exam)":
●
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).
●
If the Doctor uses the word "Cancer" bluntly without warning:
●
Reaction: Shocked and panicked. "Cancer?! You think it's cancer? In my spine? Am I going to end up paralysed?"
●
If the Doctor explains the need for urgent bloods (PSA) and an MRI scan:
●
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."

Mark Scheme

Domain 1: Data Gathering and Diagnosis

0 / 18 indicators checked+0−0

Positive (0/9)

Negative (0/9)

Domain 2: Clinical Management and Medical Complexity

0 / 20 indicators checked+0−0

Positive (0/10)

Negative (0/10)

Domain 3: Relating to Others

0 / 14 indicators checked+0−0

Positive (0/7)

Negative (0/7)

Clinical Learning Points

Recognising Non-Mechanical Back Pain

●The most clinically critical distinction in back pain is mechanical vs. non-mechanical pattern. Mechanical pain is typically worse with movement and relieved by rest. Non-mechanical pain — as in malignancy and infection — is constant, progressive, and characteristically worse when supine or at rest, often waking the patient in the early hours.
●In a patient aged over 55 presenting with back pain, a non-mechanical pattern is a red flag until proved otherwise. Do not attribute it to degenerative change or osteoarthritis without active exclusion of serious pathology.
●Additional red flags warranting urgent investigation include: unintentional weight loss, unexplained fatigue, no precipitating mechanical event, and a prolonged gap in GP monitoring.

Prostate Cancer as the Primary Differential

●Prostate cancer is the most common cancer in men in the UK and has a strong propensity to metastasise to the axial skeleton — lumbar and thoracic spine, pelvis, and ribs. Bone metastases from prostate cancer are typically osteoblastic (sclerotic), unlike the lytic lesions of myeloma.
●The combination of red-flag back pain and LUTS (nocturia, hesitancy, poor stream, incomplete voiding) in an elderly man should immediately raise the index of suspicion for a prostatic primary with skeletal involvement.
●Do not accept the patient's normalisation of LUTS as "just age." While lower urinary tract symptoms are common in older men, they remain clinically significant and warrant evaluation — particularly in this context.
●PSA is not a perfect test: it can be raised by benign prostatic hyperplasia, prostatitis, DRE, and urinary tract infection. However, in suspected metastatic prostate cancer, PSA is typically markedly elevated and should be arranged urgently alongside clinical assessment.

Investigations for Suspected Bone Malignancy

●
A targeted urgent blood panel is required when bone malignancy is suspected. This should include:
- ●FBC — anaemia (myeloma, bone marrow infiltration)
- ●ESR / CRP — elevated in malignancy and infection
- ●U&E — renal function, especially important before any NSAID prescribing and to assess for obstructive uropathy
- ●LFTs — hepatic involvement from metastatic disease
- ●Bone profile (calcium, alkaline phosphatase) — hypercalcaemia in myeloma; raised ALP in osteoblastic metastases
- ●PSA — prostate cancer screen
- ●Serum protein electrophoresis / serum free light chains — myeloma screen
- ●LDH — marker of tumour burden
●Urgent MRI whole spine is the gold-standard imaging for suspected Metastatic Spinal Cord Compression (NICE NG220). Plain X-ray is insensitive for early bone metastases and should not be used as the primary imaging modality when malignancy is suspected.

Clinical Management Pathway

●Urgent 2-week-wait (2WW) urology referral under the suspected prostate cancer pathway (NICE NG12) should be initiated for any man with LUTS and a PSA above the age-specific threshold, or where clinical suspicion of prostate cancer is high regardless of initial PSA — as in this case.
●The MSCC investigation pathway and the 2WW prostate cancer pathway are not mutually exclusive — both should be initiated in parallel. Do not delay one while awaiting results from the other.
●Analgesia is an active clinical obligation: Arthur's pain is severe and is causing sleep deprivation. Regular co-codamol 30/500 is a reasonable first step for bone pain when paracetamol alone is insufficient. Always co-prescribe a laxative when initiating an opioid in an older patient.
●NSAIDs are contraindicated or should be deferred in this clinical context: age 72, unknown renal function (likely obstructive uropathy from prostatic disease), established hypertension, and cardiovascular risk. Do not prescribe naproxen or ibuprofen until renal function is confirmed and prostatic obstruction has been excluded.
●Amlodipine should be continued unchanged. Flag that any renal impairment identified on bloods or any new medications introduced through the cancer pathway may necessitate blood pressure review.
●Acknowledge Arthur's functional goals — returning to the garden and bowling club — as legitimate clinical outcomes. Frame the investigation urgency in terms of preserving his independence, not merely finding a diagnosis. This is not merely good communication; it is essential to achieving informed consent and engagement with a complex management plan.
●Gently explore whether Arthur would be willing to let his son David know what is happening. He should not face a probable cancer diagnosis alone if support is available — but this must be his choice, not the clinician's decision.

Multiple Myeloma — Key Differential

●Multiple myeloma is the other major differential for unrelenting back pain with systemic features in an older patient. Unlike prostate metastases, myeloma produces lytic (punched-out) bone lesions and is not usually associated with LUTS.
●The classic presentation is summarised by the CRAB criteria: hyperCalcaemia, Renal impairment, Anaemia, and Bone pain / lytic lesions.
●Myeloma is often initially missed because plain X-ray of the spine can appear normal or show only non-specific degenerative change. The serum protein electrophoresis and free light chains are essential parts of the investigation panel.

Metastatic Spinal Cord Compression (MSCC) — Oncological Emergency

●MSCC occurs when tumour in the epidural space compresses the spinal cord or cauda equina, risking irreversible paralysis. It is an oncological emergency and the most time-critical safety consideration in this case.
●Early signs include radicular pain (a tight band sensation around the chest or abdomen, or shooting pain into the legs). Late signs — which indicate cord compromise — are bilateral leg weakness, saddle anaesthesia, urinary retention, or faecal incontinence.
●If any of these features develop, the patient must call 999 or attend A&E immediately — not wait for a scheduled investigation. Safety-netting for MSCC must be explicit, memorable, and action-specific: vague advice ("come back if you feel worse") is clinically inadequate.
●Where MSCC is confirmed or strongly suspected, management includes emergency whole-spine MRI and high-dose dexamethasone (16mg/day) initiated immediately to reduce cord oedema. Same-day oncology or neurosurgical input is required.

Safety Netting and Follow-up

●
Safety-netting for this case has two distinct components and both must be delivered:
1. ●MSCC symptoms — immediate 999 / A&E if leg weakness, saddle numbness, loss of bladder or bowel control develops at any point, including overnight.
2. ●Investigation follow-up — who will contact Arthur with blood results, expected timeframe, what happens next in the cancer pathway.
●A 72-year-old facing a probable serious diagnosis must not be sent away with only a request form and a vague promise of contact. Specify a named point of contact (duty doctor / named GP) and a clear timeframe for results.
●Recognise that Arthur has been socially isolated since Mary's death and has not attended his GP for two years. The follow-up plan must account for the fact that he is unlikely to self-advocate if results are delayed or if he deteriorates.

Common Candidate Mistakes

●Diagnosing mechanical back pain and prescribing an NSAID. This is the most common error in this case — and it is doubly dangerous: it misses the diagnosis and exposes Arthur to renal and cardiovascular harm from the NSAID. The combination of age, hypertension, and probable obstructive uropathy makes NSAID prescribing inappropriate before renal function is known.
●Failing to connect the LUTS to the back pain. Candidates frequently take a back pain history and treat the urinary symptoms as a separate, lower-priority finding. In this case, the connection is the diagnostic key.
●Accepting the patient's health beliefs without challenge. Arthur normalises his urinary symptoms ("all my mates have the same problem") and his weight loss ("it's the poor sleep"). Accepting these framings without exploration leads to a fundamentally incomplete picture.
●Vague safety netting. Instructing Arthur to "come back if things get worse" is not safe netting for MSCC. The instructions must specify the exact symptoms, the exact action (999 or A&E), and must not leave room for a 72-year-old in pain to minimise and delay.

Free MRCGP SCA practice case for GP registrars covering Elderly Man Has Back Pain Which Is Keeping Him Awake At Night — Musculoskeletal Health. Includes candidate brief, patient script, marking scheme mapped to the RCGP SCA marking domains, and learning points. Built directly from the RCGP curriculum topic stations listed under "How this might be tested in the MRCGP SCA," part of a free library of 79 SCA practice cases for simulated consultation assessment preparation.

← Back to Free SCA Practice Cases