I-human case study: Tina Williams "Low Back Pain"

I-human case study: Tina Williams "Low Back Pain"
Patient Profile:
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 is relieved 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, a blood 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 any
exacerbating or relieving factors.
• You could ask about the patient's occupation and physical activities, as well as
any 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 chronic
medical conditions or medications that may be contributing to the pain.

2. What physical exam maneuvers would you perform to further assess the
patient's low back pain?
To further assess the patient's low back pain, several physical exam maneuvers could
be performed, including:
• Thorough Musculoskeletal Exam: This exam includes palpation, range of
motion, and other maneuvers that evaluate the patient's posture, alignment, and
musculoskeletal structure. It is important to assess the patient's back muscles and
ligaments for tenderness, swelling, or signs of inflammation.
• Straight Leg Raise Test: This test involves lifting the patient's leg while keeping
the knee straight. A positive test reproduces the patient's pain, which suggests nerve
root irritation.
• Neurological Assessment: The examiner should evaluate for any signs of
neurological deficits, such as weakness or sensory loss in the legs. Sensory loss may
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include decreased sensation to light touch, pinprick, or temperature.
• Muscle Spasms or Trigger Points Evaluation: The examiner should evaluate for
any muscle spasms or trigger points that may be contributing to the pain. This may
include assessing the patient's muscle strength, as well as the presence of any tender
points or knots.
• Gait Assessment: The examiner should observe the patient's gait for any
abnormalities, such as limping or antalgic gait.
Overall, a thorough physical examination is crucial to accurately diagnose and
manage low back pain. It helps to identify the underlying cause of the pain, as well as
to rule out other potential causes.
3. What are your top three differential diagnoses for this patient's low back pain?