ina 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
information about his low back pain?
• You could ask about the timing and onset of the pain, as well
as anyexacerbating 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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