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.
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.
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