Low Back Pain Case Study

Demographics: Mr. S. is a 37-year-old man.
Chief Complain: He has low back pain.
1. What additional subjective data would you collect from Mr. S?
• History of present illness
 Acute or chronic: The patient experiences of acute low back pain.
 Joint complaints: He might experience of back joint dysfunction. He doesn’t experience of swelling.
 Muscular complaints: The patient has low back pain, muscle spasms, and muscle weakness.
 Medications-rx, otc and herbal supplement: He just has received some relief via taking over the counter Ibuprofen 400 mg three times daily. Whereas, he has never taken or use herbal supplements.
 Skeletal complaints: He doesn’t experience of any fractures. He just has low back pain.
 Injury: The patient might be an experience of this condition.
• Past medical
 Special maneuvers o McMurray Test: He doesn’t have any problem during this test. o Varus/valgus stress tests: The patient doesn’t suffer from pain during this tests. o Anterior and posterior drawers test: He doesn’t have a problem during this test. o Lachman test: The patient doesn’t experience of pain during this test. o Common diagnoses: He doesn’t experience of arthritis or injury to ligaments.
• Foot and Ankle
 Inspection: The patient doesn’t suffer from deformities, nodules, edema, erythema, calluses, or corns.
 Palpation: The patient doesn’t experience of swelling. He doesn’t have any problem in the ankle joint, Achilles tendon, plantar fascia, and digits. He might suffer from foot numbness or foot pain.
 Range of motion: The patient might have foot pain. He might not have problem during flexion/ extension of the ankle, inversion/eversion of the ankle, flexion/extensions of digits, abduction/adduction of digits.
• Vital Signs: The patient has regular blood pressure and pulse rate. She also has regular temperature and respiratory