Mechanical Low Back Pain (M54.5) Complicated by Class I Obesity: A Case Study – 55-Year-Old Male with Back Pain | ADVANCED CLINICAL GUIDE | SOAP Notes, Diagnostics, Final Diagnosis & EvidenceBased Care Plan

Mechanical Low Back Pain (M54.5)
Complicated by Class I Obesity: A
Case Study – 55-Year-Old Male with
Back Pain | ADVANCED CLINICAL
GUIDE | SOAP Notes, Diagnostics,
Final Diagnosis & EvidenceBased Care
Plan

,PATIENT BIODATA

Field Details

Full Name John D. (pseudonym)

Age 55 years

Sex Male

Date of Birth [Not specified – assume 1969]

Occupation IT Manager (desk-based, sedentary)

Marital Status [Not specified – assume married]

Living Situation Lives with spouse; two-story home with stairs

Primary Language English

Health Insurance [Not specified – assume commercial]

Code Status Full code (implied, no advanced directive noted)




ANTHROPOMETRIC DATA

Measurement Value

Height 1.72 m (5 ft 7.7 in)

, Measurement Value

Weight 96 kg (211.6 lbs)

Body Mass Index
32.5 kg/m²
(BMI)

BMI Classification Class I Obesity (30.0–34.9)

[Not measured – recommended: >102 cm is high
Waist Circumference
risk]




VITAL SIGNS (at presentation)

Parameter Value

Blood Pressure 128/82 mmHg

Heart Rate 72 bpm (regular)

Respiratory Rate 14 breaths/min

Temperature 36.8°C (98.2°F) – afebrile

Oxygen Saturation 98% on room air




RELEVANT SOCIAL HISTORY