Edward Carter Patient Overview
Edward Carter is a middle-aged male presenting to the clinic with chronic lower back pain that has been progressively worsening. He rates his pain at 7/10 at rest, rising to 10/10 on arrival. The pain radiates into his left leg following an L4-L5 dermatomal distribution, consistent with radiculopathy.
His history includes a documented opioid use disorder and he is currently managed under a pain contract. This history must be addressed sensitively and documented accurately — avoiding stigmatising language while still clearly recording the clinical facts is a specific competency being assessed in this module.
PQRSTU Pain Evaluation — Complete Documentation
The PQRSTU framework structures the complete pain history:
P — Provocative/Palliative: Pain worsens with prolonged standing and walking. Relieved by lying down flat. NSAIDs provide minimal relief. Heat application moderately helpful.
Q — Quality: Sharp and burning in the lower back. Shooting, electric sensation down the left leg in the L4-L5 dermatomal distribution.
R — Region/Radiation: Lower back, radiating into the left buttock and down the posterior left leg to the knee. Paresthesia in the left foot.
S — Severity: 7/10 at rest. 10/10 on arrival and with movement. Functional impact: cannot stand for more than 10 minutes, has stopped working.
T — Timing: Constant with episodic exacerbations. Present for 18 months, worsening over past 6 weeks.
U — Understanding: Patient understands his pain is from disc herniation. Expresses frustration that previous treatments have not been effective. Fears becoming permanently disabled.
Physical Examination Findings
The physical examination in this module tests your ability to conduct a targeted neurological and musculoskeletal assessment for a patient with suspected radiculopathy:
Straight Leg Raise: Positive on the left at 40 degrees. Reproduces the radiating pain into the left leg. Negative on the right.
Sensory Testing: Decreased sensation to light touch in the L4-L5 dermatome on the left. Normal on the right.
Motor Strength: 4/5 left lower extremity (dorsiflexion weakness). 5/5 right lower extremity and both upper extremities.
Reflexes: Diminished patellar reflex on the left compared to right. Normal Achilles reflex bilaterally.
Diagnosis: Chronic low back pain with left L4-L5 radiculopathy. MRI referral indicated.
Opioid History and Psychosocial Screening
A significant portion of the scoring in this module relates to how you handle Edward's opioid use history. The key principles:
Use person-first language — "patient has a history of opioid use disorder" not "patient is an addict." Document the current pain contract clearly. Screen for depression and social isolation related to chronic pain — both are present and must be documented. Assess his support system and ability to perform activities of daily living independently.
The psychosocial screening should include a PHQ-2 or brief depression screen, functional impact on ADLs, social support assessment and coping strategies currently in use.
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