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Exam (elaborations)

I-HUMAN CASE STUDY: LOW BACK PAIN

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I-HUMAN CASE STUDY: LOW BACK PAIN Patient Profile: I-HUMAN CASE STUDY: LOW BACK PAIN Tina is a 52-year-old male who presents to the primary care clinic with complaints of low back pain. He reports that the pain started a few weeks ago and has been gradually worsening. He describes the pain as a constant ache that is present in his lower back and sometimes radiates down his right leg. The pain is worse with standing and walking and isrelieved when he lies down. The patient reports no history of trauma or injury to the back,and he denies any weakness or numbness in his legs. He has tried over-the-counter pain medication, which provides some relief, but the pain persists. Initial Assessment: Upon examination, the patient is alert and oriented, with a heart rate of 80 beats per minute, ablood pressure of 130/80 mmHg, and a respiratory rate of 16 breaths per minute. His lower back is tender to palpation, and he has limited range of motion. Straight leg raise test is positive on the right side, which reproduces the pain in the leg. Neurological examination of the lower extremities is normal, with no weakness or sensory deficits. Case Questions with solutions: 1. What additional questions would you ask the patient to gather more informationabout his low back pain? • You could ask about the timing and onset of the pain, as well as any exacerbating or relieving factors. • You could ask about the patient's occupation and physical activities, as well asany recent changes in his work or exercise routine. • You could ask about the presence of any previous back pain or injuries. • You could ask about the patient's medical history, including any chronicmedical conditions or medications that may be contributing to the pain.

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Written in
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