Altered Sensation

Name: Kylian Peterson

Age: 60 Years Old

Date of Birth: 2nd February 1964

Location: Emergency Department

Occupation: Retired Sales Representative

“I feel like my legs aren’t mine anymore!”.

• Onset: Started this morning in both my legs, down to the toes

• Progression: Came on quite suddenly and got worse over time.  

• Exacerbating Factors: None

• Relieving Factors: Nothing makes it go away.

• Associated symptoms: Lower back pain characterised as a severe ache rated 9/10 on the pain scale, loss of sensation in areas surrounding back-passage (peri-anal)

• Timing: Constantly there

• Precipitating Factors : Started early in the morning as soon as I got out of bed. Not sure of triggers but may be because I was carrying some heavy boxes when cleaning up my backyard yesterday. 

• Recent illness: None.

• Recent back trauma: None. 

• Recent travel: None.

• Previous episodes: Never experienced this before.

• Ideas: “I don’t know!”

• Expectations: “Do I need surgery?”

• Concerns: “I’m just worried this is something sinister like cancer.”

• Bowel habits: Lost control of bowel opening

• Urinary habits: Have been experiencing troubles urinating, and when am able to wee, there is a loss of sensation of urinating. Urine appears normal in colour.

• Appetite: Same as usual.

• Sleep: Same as usual

• Weight: No change 

• Pain in the chest/abdomen: None

• Headaches: None

• Fever: None

• Cardiology: Normal

• Respiratory: Normal

• Ophthalmology: Normal

• Upper limb neurology: Normal

• No pain in lower limbs

Previous hospital admissions: None

Previous surgeries: None

Medical conditions:

• I’m always healthy other than a bit of a high blood pressure! I manage it with just lifestyle modifications.

Medications:

• None

Over the counters:

• Paracetamol for back pain. No effect.

Allergies:

• None.

Everyone in the family is healthy and well.

• Smoking: Smokes 2 cigarettes a day for the past 30 years

• Alcohol: I don’t drink at all!

• Recreational drugs: Never

• Diet: My wife cooks at home, sometimes we do go out for meals but we watch our diet carefully

• Exercise: I go for walks every morning  

• Ill contacts: No one around me was recently ill

• Home: Lives with wife in a terraced single-storey house

• Active Daily Living: Usually mobile and able to perform daily functions normally.

• Occupation: Used to work as a builder before becoming a sales rep. I’m now retired.