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i-HUMAN CASE STUDY: TINA WILLIAMS WITH LOW BACK PAIN | REAL QUESTIONS AND ANSWERS
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
lOMoARcPSD|28578405
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
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