PRESENTING WITH BACK PAIN AT OUTPATIENT CLINIC
WITH LABORATORY AND IMAGING CAPABILITIES
,PATIENT INFORMATION
Name: Not provided
Age: 54 years
Sex: Male
Height: 5′10″ (178 cm)
Weight: 155.0 lb (70.5 kg)
Location: Outpatient clinic with X-ray, ECG, and laboratory capabilities
Reason for Encounter: Back pain
The patient is a 54-year-old male presenting with acute low back pain that began several days ago,
most pronounced in the lower lumbar region, interfering with mobility and activities of daily living.
Evaluation focuses on clarifying etiology, ruling out red flag conditions, and formulating a
management plan.
, REASON FOR ENCOUNTER
The patient presents for evaluation of low back pain that has persisted for approximately one week
and is aggravated by movement and prolonged sitting or standing. The encounter aims to
differentiate between mechanical and serious underlying causes and provide evidence-based
diagnosis and management.
Component Description
Encounter type Outpatient clinic visit
Chief complaint Back pain
Onset Approximately 7–14 days ago
Duration Persistent, daily
Location Lower back (lumbar region)
Characteristics Dull, aching pain; intermittent radiation to buttock
Aggravating factors Movement, bending, prolonged standing/sitting
Relieving factors Rest, positional changes
Associated symptoms Mild morning stiffness, sleep disturbance
Systemic concerns No fever, chills, bowel/bladder changes
Patient goals Identify cause, relieve pain, restore function