Pain Management Triage

Injury History

• Pt (Thabo Mokoena, 54M, ID: 700412 5082 084) sustained an acute mechanical lower back injury on 15/10/2023 at his workplace warehouse in Johannesburg while lifting a 25 kg crate, resulting in immediate lumbar pain and muscle spasm.

Current Pain Experience

• Constant dull ache in the lumbosacral region (L4-S1) rated 6/10 at rest, escalating to 9/10 sharp, shooting pain radiating down the right posterior thigh to the calf upon lumbar flexion or prolonged standing (> 15 mins). Associated with intermittent right L5 dermatome paraesthesia; no saddle anaesthesia or sphincter disturbance.

Medical

• HPT, T2DM, and previous L4/L5 microdiscectomy (2018).
• Metformin (Glucophage®) 850 mg PO BID, amlodipine (Norvasc®) 5 mg PO OD, paracetamol (Panado®) 1,000 mg PO QID PRN, and tramadol (Tramal®) 50 mg PO TID PRN.
• Penicillin (maculopapular rash); NSAIDs contraindicated due to stage 2 CKD.

Cultural Considerations/Individual Needs

-Observant Christian; strong family support system involved in decision-making. Fluent in English and Sesotho.

• Prefers conservative, non-surgical management and physiotherapy; requests avoidance of strong opioids due to sedation concerns affecting his ability to drive.

Impact of Pain

• Currently on temporary light duty; unable to perform manual labour. Sleep is disrupted (awakens 2-3 times/night), leading to daytime fatigue, irritability, and strained marital interactions.
• Independent in basic ADLs, though slow with dressing (putting on socks/shoes). Antalgic gait observed; sitting tolerance limited to 20 mins, and lifting restricted to < 5 kg.