Case: Eva-May          

First Visit - The Initial Assessment

Eva-May is a 62 year old woman who presents complaining of one week of low back pain (LBP). The pain is severe enough to limit her normal activities. She missed the last three days of work.

She noted the pain one morning and it became worse over the next few days. She describes it as an "ache throughout my lower back". It does not radiate. She finds prolonged sitting makes it worse and this affects her ability to do her secretarial work. Bed rest helps a little and the pain does not affect her sleep. Walking does not make the pain worse.

No history of recent falls or accidents, recent infections, fevers or weight loss. She states that she has no trouble passing urine. She does not smoke and has no other health problems.

PAST: Eva-May reports that she has had previous episodes of LBP which were shorter and less disabling. She has no history of cancer.

WORK: She is a legal secretary and wants to return to work soon. She gets along well with her co-workers and supervisor. She is satisfied with her job and does not find it stressful. Occasionally she has to work extra hours but this does not bother her.

FAMILY: Eva-May is divorced and has two married daughters. One daughter is married to an alcoholic who is unemployed. They are having increasing financial difficulties and the daughter plans to separate from her husband.

EXPECTATIONS: Eva-May does not appear overly concerned about her LBP and expects it to resolve soon. She seems more preoccupied with her daughter's problems.

Click to see the Red Flags, Pink Flags, or Key Questions on this case.