Scenario: A 59-year-old female presents with complaints of low back pain. She reports having difficulty standing upright and must change position frequently when sitting or lying down. She denies any specific incident that preceded the pain, stating that it just started as stiffness, but it has progressively worsened. When asked about pain radiation, the patient confirms that pain is radiating down to her mid-thighs, bilaterally. The patient reports that her activities are limited by the pain despite the use of acetaminophen, ibuprofen, and ice. A full physical exam is needed to determine the cause of pain and to identify treatment options.
1. The patient reports activity intolerance as a result of the low back pain. What should you include when performing your initial physical assessment?
2. What questions should you ask to appropriately gather this patient’s history?
3. The patient seems surprised when you begin asking questions about her psychosocial status. Why is a psychosocial evaluation important for patients with low back pain?
4. Concerned that “something serious” is going on, the patient insists on having an x-ray to be certain. To warrant an order for an x-ray (radiograph) for acute low back pain (ALBP), what conditions should exist?
5. You inform the patient that most ALBP episodes (almost 90%) resolve within 1 to 6 weeks and that pain management will focus on symptom control through pharmacological and nonpharmacological methods. What is your plan of care for this patient? Provide full prescription details if medications are ordered.
6 What will you include in patient education and instructions?
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