iHuman Back Pain Case Study Week 9
(55-Year-Old Male) – Full Patient Case
Analysis, H&P, SOAP Notes, Diagnosis &
Management Plan
Patient Case Analysis
1. Patient Information
Name: Adult Male
Age: 55 years
Sex: Male
Height: 178 cm
Weight: 111.4 kg
Chief Complaint:
"Back pain."
2. History Questions (Important Questions to Ask)
History of Present Illness (HPI)
,When did the back pain start?
Was the onset sudden or gradual?
Where exactly is the pain located (lower, mid, or upper back)?
Does the pain radiate to the legs or buttocks?
How would you describe the pain (sharp, dull, aching, burning)?
What is the severity of the pain (scale 1–10)?
Is the pain constant or intermittent?
What activities worsen the pain (lifting, bending, sitting, standing)?
What relieves the pain (rest, medications, position changes)?
Any history of trauma, fall, or heavy lifting?
Is there morning stiffness? If yes, how long does it last?
Any numbness, tingling, or weakness in the legs?
Any difficulty walking or maintaining balance?
Any loss of bowel or bladder control (red flag)?
Associated Symptoms
Fever
Weight loss
Fatigue
Night pain
Neurological symptoms
Abdominal pain
Past Medical History
History of chronic back pain
Obesity
Hypertension
Diabetes
Arthritis
Medication History
Current medications
Pain relievers (NSAIDs, opioids)
Steroid use
Social History
Occupation (manual labor vs sedentary)
Physical activity level
Smoking history
Alcohol use
,3. Physical Examination
General Appearance
Middle-aged male
Overweight/obese
May appear uncomfortable due to pain
Vital Signs
Blood Pressure: May be elevated
Heart Rate: Normal
Respiratory Rate: Normal
Temperature: Normal
Musculoskeletal Examination
Inspect posture and spinal alignment
Palpate spine for tenderness
Assess range of motion (flexion, extension, rotation)
Check for muscle spasms
Neurological Examination
Assess lower limb strength
Check reflexes (knee, ankle)
Evaluate sensation
Assess gait
Special Tests
Straight leg raise test
Evaluate for radiculopathy
Red Flag Assessment
Severe neurological deficits
Loss of bowel/bladder control
Signs of infection or malignancy
4. Key Findings
, Back pain in a middle-aged obese male
Possible mechanical strain
Reduced mobility
Potential occupational risk factors
No immediate red flag symptoms (if absent)
Risk factors include obesity and possible sedentary lifestyle
These findings suggest mechanical low back pain with possible degenerative changes.
5. Diagnostic Tests
Initial Tests
X-ray of lumbar spine
Assess for degenerative changes
Laboratory Tests
CBC
Inflammatory markers (ESR, CRP)
Advanced Imaging
MRI (if neurological symptoms present)
CT scan (if structural abnormalities suspected)
Additional Tests
Blood glucose (diabetes screening)
Lipid profile
6. Differential Diagnosis
1. Mechanical Low Back Pain
Most common
Related to muscle strain or poor posture
2. Lumbar Disc Herniation
(55-Year-Old Male) – Full Patient Case
Analysis, H&P, SOAP Notes, Diagnosis &
Management Plan
Patient Case Analysis
1. Patient Information
Name: Adult Male
Age: 55 years
Sex: Male
Height: 178 cm
Weight: 111.4 kg
Chief Complaint:
"Back pain."
2. History Questions (Important Questions to Ask)
History of Present Illness (HPI)
,When did the back pain start?
Was the onset sudden or gradual?
Where exactly is the pain located (lower, mid, or upper back)?
Does the pain radiate to the legs or buttocks?
How would you describe the pain (sharp, dull, aching, burning)?
What is the severity of the pain (scale 1–10)?
Is the pain constant or intermittent?
What activities worsen the pain (lifting, bending, sitting, standing)?
What relieves the pain (rest, medications, position changes)?
Any history of trauma, fall, or heavy lifting?
Is there morning stiffness? If yes, how long does it last?
Any numbness, tingling, or weakness in the legs?
Any difficulty walking or maintaining balance?
Any loss of bowel or bladder control (red flag)?
Associated Symptoms
Fever
Weight loss
Fatigue
Night pain
Neurological symptoms
Abdominal pain
Past Medical History
History of chronic back pain
Obesity
Hypertension
Diabetes
Arthritis
Medication History
Current medications
Pain relievers (NSAIDs, opioids)
Steroid use
Social History
Occupation (manual labor vs sedentary)
Physical activity level
Smoking history
Alcohol use
,3. Physical Examination
General Appearance
Middle-aged male
Overweight/obese
May appear uncomfortable due to pain
Vital Signs
Blood Pressure: May be elevated
Heart Rate: Normal
Respiratory Rate: Normal
Temperature: Normal
Musculoskeletal Examination
Inspect posture and spinal alignment
Palpate spine for tenderness
Assess range of motion (flexion, extension, rotation)
Check for muscle spasms
Neurological Examination
Assess lower limb strength
Check reflexes (knee, ankle)
Evaluate sensation
Assess gait
Special Tests
Straight leg raise test
Evaluate for radiculopathy
Red Flag Assessment
Severe neurological deficits
Loss of bowel/bladder control
Signs of infection or malignancy
4. Key Findings
, Back pain in a middle-aged obese male
Possible mechanical strain
Reduced mobility
Potential occupational risk factors
No immediate red flag symptoms (if absent)
Risk factors include obesity and possible sedentary lifestyle
These findings suggest mechanical low back pain with possible degenerative changes.
5. Diagnostic Tests
Initial Tests
X-ray of lumbar spine
Assess for degenerative changes
Laboratory Tests
CBC
Inflammatory markers (ESR, CRP)
Advanced Imaging
MRI (if neurological symptoms present)
CT scan (if structural abnormalities suspected)
Additional Tests
Blood glucose (diabetes screening)
Lipid profile
6. Differential Diagnosis
1. Mechanical Low Back Pain
Most common
Related to muscle strain or poor posture
2. Lumbar Disc Herniation
