Cases/Musculoskeletal Health

Sciatica Asking for A Scan and Stronger Painkillers — Free SCA Practice Case

Warehouse worker with sciatica asking for a scan and stronger painkillers

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

Try 5 free cases

Five cases are free: a live 12-minute consultation with an AI patient each, marked, and no card.

Materials for Candidate

Please review before starting the consultation

Patient Profile

Full Name

Gavin Abbott

Age

42 years

Consultation Type

Video

Age

Situation

Video Consultation. Routine appointment booked by the patient.

Reason for Encounter

"Pain down the left leg for four weeks. Would like a scan and something stronger for the pain."

Medical Records

●PMH: Dyspepsia 3 years ago, treated with a short course of omeprazole and settled. Low back pain 6 years ago, settled within a fortnight.
●Medications: None on repeat.
●Allergies: NKDA.
●Social: Warehouse operative. Non smoker.

Recent Notes

●Nurse telephone triage, 4 days ago: Left leg pain for 3 weeks, no further details recorded. Booked to see a GP.

Patient Script

For the friend playing the patient role

Character Overview: You are Gavin Abbott, a 42 year old warehouse operative at a large distribution centre. You pick and load orders on a mix of early and late shifts and lift boxes most of the day. You live with your partner Kerry, who works part time as a teaching assistant, and your two children, aged 9 and 12. You are the main earner and have worked at the distribution centre for six years, but the company pays only statutory sick pay when you are off, and your family could not manage on that for long. For four weeks you have had pain shooting down your left leg. You assume it is a slipped disc like your brother Wesley, who had an MRI scan and has taken pregabalin for over a year for his leg. You want the same: a scan to see what is wrong and tablets that actually work. You are practical, a bit gruff and short on patience, but you soften when your family comes up. You speak plainly, and your voice goes tight and quiet when you talk about money.

Opening Sentence: "Morning, doctor. I've had this pain shooting down my left leg for about a month now and the tablets from the chemist aren't touching it. My brother had a scan and he's on pregabalin for his leg, so I'd like the same, please. I really can't afford to be off work."

History if Asked (Data Gathering Phase)

●How it started: "About four weeks ago. I'd done a long run of heavy loading, and the next morning my lower back was stiff. A couple of days later the pain started in my left buttock and went down my leg. There was no fall and no single moment where I felt something go."
●Where it goes: "Left buttock, down the back of my thigh, then the outside of my calf and over the top of my foot to my big toe. Only the left. The right leg is fine."
●What it feels like: "Sharp, like an electric shock, with a deep ache behind it. Seven out of ten most of the day. It shoots to nine when I cough or sneeze, or if I sit for more than twenty minutes."
●The back itself: "My lower back is stiff, but it's the leg that's the problem. The back is about a three."
●Pins and needles: "On top of my foot and in my big toe, on and off. It isn't numb, just tingly."
●Weakness: "No. My foot isn't dragging and my leg hasn't given way. It just hurts."
●What eases and worsens it: "Walking about eases it, which is why I'm just about managing at work. Sitting, bending forward and lifting make it worse. Lying flat is okay."
●Nights: "It wakes me if I roll onto my left side, but I shift position and go back to sleep. It isn't there every night all night."
●Progress: "About the same, maybe a bit worse this last week."
●What he has taken: "Ibuprofen 400 from the chemist, three times a day for about two weeks. It takes the edge off for a few hours, but it gives me heartburn, even with food. Paracetamol does nothing. A heat pad helps a bit."
●Other things tried: "Some stretches off YouTube. They set it off, so I stopped."
●Time off: "Two days last week. I rang in sick on the Wednesday and Thursday. We definitely felt it in the wage."

Ideas, Concerns, Expectations

Gating note: Gavin does not raise any of the following himself. Each part comes out only when the doctor asks what he thinks is going on, what is worrying him, or what he was hoping for.

●Ideas: He thinks a disc in his back has slipped, because that is what his brother Wesley was told. He believes a scan is the only way anyone can really see what is wrong. "I reckon it's a disc, same as Wesley. Nobody can tell what's going on in there without a scan, can they?"
●Concerns: His main worry is money. He is the main earner, Kerry only works part time, and the company pays nothing above statutory sick pay, so the family could not manage for long if he were off. He also fears ending up like Wesley, who had an operation and still can't work properly. "If I'm off for weeks on sick pay I don't know what we'd do. Kerry's job is only part time. And Wesley had an operation and he's still not right. I don't want to end up like that."
●Expectations: He came for an MRI scan and a tablet like his brother's. He also hopes the scan result will prove to his employer that the problem is real. "A scan, and the same tablets as Wesley. If the scan shows it, work can't say I'm making it up."

If Asked: Medical History and Medications

Gating note: Gavin answers each of these plainly when the doctor asks about it.

●Other health problems: "Nothing else. I had heartburn about three years ago and had omeprazole for a few weeks. It cleared up. I had a bad back once about six years ago and it was gone in a fortnight."
●Medicines: "Only the ibuprofen from the chemist. I get no prescription tablets and take no herbal stuff."
●Asthma, kidneys, blood pressure, ulcers or bleeding: "No asthma, no kidney trouble, no ulcers and I've never had a bleed. My blood pressure was fine at my work medical."
●Allergies: "None."
●Mood: "Stressed and sleeping badly because of the pain and the money, but I'm not depressed. I've never had low mood or thoughts of harming myself."
●Wesley's tablets: "Pregabalin, over a year now. He says it makes him foggy and he can't seem to stop it."

Social History and Lifestyle Impact

●Work: Gavin picks and loads orders at a distribution centre, mostly lifting boxes of up to about 15 kilograms. If asked about adjustments, he says there is a goods in desk where parcels are scanned and sorted, and he could do that for a while, but he has not asked in case they think he is swinging the lead. If asked about sick pay or money: "They only pay the statutory. I'm the main wage, Kerry's only part time."
●Home: Lives with Kerry and the children. He is sleeping badly and has been snappy with the kids.
●Smoking and alcohol: Has never smoked. A few pints on a Saturday, nothing in the week.
●Weight and activity: About 15 stone. He has not played five a side football for a month.
●Availability to be seen: On earlies this week and finishing at 2 o'clock, so he could come to the surgery after work or on Thursday morning.

If Asked: Associated Symptoms

Gating note: Gavin answers these only when asked. Every one is negative unless stated.

●If asked about bladder or bowel: "No change at all. I pass water normally and I've not had any accidents or trouble holding it. Bowels are normal."
●If asked about numbness around the bottom, genitals or inner thighs, or sexual function: "No, nothing down there and no problems."
●If asked about pain or tingling in the other leg, or both legs: "No, only the left."
●If asked about fever, feeling unwell or weight loss: "No. I feel well in myself and my weight is the same."
●If asked about cancer, steroids, injecting drugs, or a weak immune system: "No to all of that."
●If asked about a fall, accident, injury or thin bones: "No."
●If asked about pain that is constant and unrelenting through the night: "No, only when I roll onto it."

Responses to Management (The Negotiation Phase)

●
If the doctor explains why he does not need an MRI scan:
- ●Reaction: Sceptical. "But Wesley got one. How will you know what's wrong without it?" He accepts if told that most people improve without one and the scan would not change what is done now. "So when would I get one?" He is reassured to hear that a scan can be arranged by a specialist if it would change the plan. "Fair enough, but what do I tell my supervisor?"
●
If the doctor explains why pregabalin is not recommended:
- ●Reaction: Surprised. "But it works for Wesley." If told it has not helped people with this kind of pain and can cause drowsiness, dizziness and dependence: "He did say it makes him foggy. I don't want that, I drive to work and I've got the kids." He asks what else there is.
●
If the doctor suggests an anti inflammatory tablet with something to protect the stomach, or an alternative if that is unsuitable:
- ●Reaction: Practical. "I'm already on ibuprofen and it gives me heartburn." Once told what is different, how long to take it and what to watch for: "Right, so a stomach tablet with it, for a short time. How long can I stay on it?" If a stronger painkiller is mentioned: "Is that addictive? I don't want to end up like Wesley."
●
If the doctor discusses work, a fit note or occupational health:
- ●Reaction: Anxious, then relieved. "If I'm signed off, is it just the sick pay? We can't live on that." If offered a note saying he can work with changes, or a suggestion to ask for the goods in desk: "I could ask about that. Would you write it down so they can't say no?" If told to stay off work completely: "That's two weeks I haven't got, doctor."
●
If the doctor says he needs to be examined in person, or suggests exercises, physiotherapy or a specialist musculoskeletal referral:
- ●Reaction: Relieved to be taken seriously. "Yes, nobody has actually checked my leg. I can come after work today or Thursday morning." If asked to test his own strength or reflexes on screen, he declines: "I wouldn't know what I was doing. Can't you just check me when I'm in?" About exercise: "Will moving about make it worse? The YouTube stretches did."
●
If the doctor describes the outlook or gives safety netting:
- ●Reaction: Wants specifics. "How long will this last? Will it come back?" If safety netting is vague, such as "come back if it gets worse": "Worse how? It's bad already. What would mean I need to come in straight away?" He repeats back clearly when given specific symptoms and what to do.

Mark Scheme

Domain 1: Data Gathering and Diagnosis

0 / 16 indicators checked+0−0

Positive (0/8)

Negative (0/8)

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

The Core Dilemma and the Model Plan

●Gavin has four weeks of left sided leg pain below the knee with tingling in the foot, no red flags on history, and a firm belief that he needs an MRI (magnetic resonance imaging) scan and pregabalin because his brother has both. The station tests holding a line on evidence while keeping a worried man engaged and his job protected.
●The model plan has six parts. Take a focused history that screens for red flags. Arrange an in person neurological examination, because power, sensation, reflexes and straight leg raising cannot be done on video. Do not request imaging in primary care. Do not prescribe pregabalin. Offer a safe, time limited analgesic plan with self management advice. Address work with a fit note that supports adjusted duties. Finish with specific safety netting and review within two weeks.
●Acceptable alternatives: examining first and prescribing at the face to face visit, or prescribing after a history and arranging the examination within days. Referral to the musculoskeletal (MSK) service now, because symptoms have lasted four weeks and limit work, or at the two week review if no better, are both reasonable. A short fit note with a clear return plan is acceptable if the pain truly prevents him working.

Recognising Sciatica

●NICE Clinical Knowledge Summaries (CKS, revised August 2026) describe sciatica as pain, tingling or numbness from irritation or compression of a lumbosacral nerve root. About 90% of cases are caused by a herniated disc.
●Features suggesting sciatica include unilateral leg pain radiating below the knee to the foot or toes, pain that may be burning or sharp, worse with lumbar flexion, coughing or sitting, back pain that is less severe than the leg pain, tingling in a nerve root distribution, and sometimes weakness or reflex change. Gavin's pain follows an L5 pattern, down the outer calf to the big toe.
●Most people improve within a few weeks to months with conservative management, but recurrence is common. Smoking, higher body weight, physical inactivity and heavy physical work are risk factors. Gavin has two of the four, higher body weight and heavy physical work, and he does not smoke.
●Diagnosis rests on history and examination, not imaging.

Red Flags and Why They Are Asked

●CKS lists red flags suggesting serious pathology: bladder or bowel dysfunction, saddle numbness, severe or progressive neurological weakness, sudden bilateral radicular symptoms, immunosuppression or prolonged steroid use, unexplained weight loss, past cancer, known osteoporosis with new severe spinal pain, and incapacitating or unrelenting night pain.
●Suspected cauda equina syndrome needs emergency referral to a spinal surgery service, usually via an emergency department with access to emergency MRI. Bilateral radicular pain, major motor loss, cancer or suspected cancer, and being objectively unwell with spinal pain need urgent or priority referral.
●All of Gavin's screening answers are negative. Asking about each group, in plain words, is what earns the marks, and a negative history still needs a neurological examination.

Why Not an MRI Scan

●The NICE guideline on low back pain and sciatica (NG59, last updated July 2026) says not to routinely offer imaging in a non specialist setting for people with low back pain with or without sciatica. Imaging should be considered in specialist settings only if the result is likely to change management, for example before an epidural injection or surgery.
●Most disc related sciatica improves without intervention, and scans often show changes that cause worry without helping. His hope that a scan will convince his employer is understandable but is not a clinical indication.
●If he is referred for a specialist opinion, he may not need imaging first. A good answer explains this and says exactly when a scan would become relevant: persistent severe pain despite treatment, a decision to consider epidural or surgery, or new red flags.
●Emergency imaging is for suspected cauda equina syndrome or other red flags, not for a man with four weeks of unilateral pain, no neurological deficit and no red flags.

Medicines: What to Offer and What Not to Offer

●NG59 and CKS state clearly: do not offer gabapentinoids (pregabalin, gabapentin), other antiepileptics, oral corticosteroids or benzodiazepines for sciatica, because there is no overall evidence of benefit and there is evidence of harm. Do not offer opioids for chronic sciatica. CKS also advises against paracetamol for sciatica.
●Pregabalin and gabapentin can cause drowsiness, dizziness and weight gain, and carry a risk of misuse and dependence. Pregabalin has been a Class C, Schedule 3 controlled drug since 2019. Gavin drives to work, and his brother already finds it hard to stop.
●NSAIDs (non steroidal anti inflammatory drugs) are the main option. NG59 says to be aware of the risk of harm and limited evidence of benefit in sciatica. If prescribing, consider gastrointestinal, liver and cardio renal risk, use gastroprotection where appropriate, and give the lowest effective dose for the shortest possible time. Gavin already has heartburn on over the counter ibuprofen and a past course of omeprazole, so an NSAID with a proton pump inhibitor is reasonable, and a candidate who judges the risk to be too high and offers a different plan can also pass.
●For acute low back pain, NG59 allows a weak opioid, with or without paracetamol, only if an NSAID is contraindicated, not tolerated or ineffective. For sciatica this is a short course at most, with the risks explained in line with NICE guidance on medicines associated with dependence or withdrawal symptoms (NG215). Tricyclic antidepressants have uncertain evidence in sciatica.
●If a patient already takes a gabapentinoid or opioid for sciatica, explain the risks of continuing and discuss withdrawal, as Wesley's doctors should.

Self Management, Exercise and Physical Treatments

●Offer information about the nature of the problem, encourage normal activities and reassure about recovery. Bed rest is not recommended and long periods in one position should be avoided. Local heat may help. A modest increase in pain on returning to activity does not mean damage.
●Give written exercises, such as the NHS leaflets, and explain that the stretches Gavin tried may have been too aggressive. Do not recommend a corset, foot orthotics, rocker sole shoes, traction, acupuncture, ultrasound or electrical stimulation, which NG59 advises against.
●NG59 supports risk stratification with a tool such as STarT Back. Higher risk of a poor outcome, which poor sleep, stress and money worry may suggest, favours a group exercise programme or physiotherapy that includes exercise, with manual therapy only as part of that package.
●Brief advice on weight and staying active helps recovery and reduces recurrence, if raised without blame.

Work and the Fit Note

●NG59 says to promote and facilitate return to work or normal activities. CKS advises considering work adjustments, discussing occupational health where available, and avoiding heavy lifting and awkward or prolonged postures.
●Gavin can walk, is already working shifts, and a goods in desk role exists. A fit note saying he may be fit for work with amended duties, for example no lifting over a stated weight, is a better answer than a full sign off. The fit note statement does not need the employer's agreement, but a clear note gives him something concrete to show his supervisor.
●If pain is too severe for any duties, a short sign off with a review is acceptable. Signing him off for weeks by default risks both deconditioning and a household income his family cannot absorb on statutory sick pay.
●Employers' policies vary, so the doctor cannot promise an outcome, but can make the note clear.

Safety Netting, Follow Up and Referral

●Follow up within two weeks of the first presentation, as CKS advises. Advise the patient to seek review sooner if pain is worsening, severe pain has not eased within a week, or new symptoms develop.
●Safety netting must name the symptoms and the action: new difficulty passing urine, loss of bladder or bowel control, numbness around the genitals or bottom, new sexual dysfunction, pain spreading to the other leg, or worsening weakness or numbness need same day emergency assessment.
●Refer to the local MSK service if sciatica persists beyond four weeks and significantly impairs daily activities, or if sciatic pain is severe at two to six weeks and not helped by initial measures. NG59 supports considering an epidural for acute and severe sciatica, and spinal decompression when non surgical treatment has not improved pain or function and imaging is consistent with the symptoms. These are specialist decisions.

Common Mistakes in This Station

●Agreeing to an MRI to end the argument, or refusing it bluntly without explaining when a scan might be arranged by a specialist.
●Prescribing pregabalin because his brother has it, or offering paracetamol alone as if it were enough.
●Prescribing an NSAID without noticing his heartburn, or without a time limit and stomach protection.
●Diagnosing and treating entirely over video without arranging an examination, or asking Gavin to test his own strength on screen.
●Signing him off for a long period without discussing adjusted duties, or ignoring the money worry.
●Safety netting with "come back if it gets worse" and no named symptoms.
●Using the term "saddle anaesthesia" without explaining it.

Mapped to the RCGP curriculum topic: Musculoskeletal Health.

← Back to Free SCA Practice Cases