“66-Year-Old Female with Back Pain I-Human Case Study – Full Analysis, Diagnosis, Pathophysiology & Management Explained”2026

Patient: Margaret Collins Age / Sex: 66 years old / Female Chief Complaint: Back pain Height / Weight: 5' 1" (155 cm) / 165.0 lb (74.8 kg) | BMI: 31.2 i-Human Patients Academic Team | Full Case Study Including Pathophysiology, Reasoning, and Broader Implications | For Educational Use I-Human Case Study | 66-Year-Old Female with Back Pain | Week #9 2 | P a g e Case Week: i-Human Case Week #9 Setting: Primary Care Clinic Case Author: i-Human Patients Academic Team i-Human Patients Academic Team | Full Case Study Including Pathophysiology, Reasoning, and Broader Implications | For Educational Use I-Human Case Study | 66-Year-Old Female with Back Pain | Week #9 3 | P a g e i-Human Patients Academic Team | Full Case Study Including Pathophysiology, Reasoning, and Broader Implications | For Educational Use 2 | P a g e HISTORY FEEDBACK — PERFORMED VS. MISSED QUESTIONS Ask relevant problem-focused questions to create an accurate initial differential diagnosis list. Various questions may yield the same information. Examples of high-yield questions for this case include: ● Performed Missed ●/ Category Question Patient Response ● HPI How can I help you today? My back really hurts. ● HPI Do you have any other symptoms or concerns we should discuss? Yes — the pain makes it hard to sleep and gets worse when I am walking. But otherwise, nothing else. ● HPI What are the events surrounding the start of your back pain? I was rearranging heavy tables at the restaurant where I work. I do it all the time but this time I must have moved them wrong. ● HPI When did the pain in your back start? Four days ago. ● HPI How long does your back pain last? I hope it won't last long. This is horrible! ● HPI What does the pain in your back feel like? Sharp. ● HPI How severe (1–10 scale) is the pain in your back? About 7. ● HPI Where more precisely is the pain in your back? It's in my lower back. It starts right here (puts the palm of her hand on her lower back). ● HPI Does the pain in your back radiate someplace else? Where? I have pain in my right leg now also. ● HPI Does the pain in your back come and go? I wish it would go... No, it's continuous. ● HPI Does anything make the pain in your back better or worse? Moving hurts more. Even rolling over in bed... or walking. I tried the ibuprofen like the urgent care recommended but it's not working. ● HPI What treatments have you had for the pain in your back? Just the ibuprofen the urgent care gave me. It doesn't seem to be doing much. ● Symptom Do you have any tingling and/or numbness anywhere? Yes, it's in my right leg. I have shooting pain all the way down that side too. It's pretty painful. ROS Do you have fever, chills, or unexplained weight loss? Not asked — critical to rule out infectious or malignant etiology PMH Do you have a history of osteoporosis or fractures? Not asked — important for 66-year-old female with back pain ● PMH Do you have any other medical problems? I have high blood pressure and I take medication for it. I had a hysterectomy years ago. ● Allergy Do you have any allergies to medications? I'm allergic to penicillin — it gives me hives. ● Social Hx What is your occupation? I am a restaurant worker. I do a lot of lifting and moving. Patient Profile: I-Human Case Study | 66-Year-Old Female with Back Pain | Week #9 4 | P a g e 66-year-old female who presents to the primary care clinic with complaints of low back pain. She reports that the pain started four days ago while rearranging heavy tables at the restaurant where she works. She describes the pain as sharp, rated 7/10, located in her lower back, and radiating down her right leg. The pain is continuous, worsens with movement and walking, and is relieved minimally when lying still. The patient reports shooting pain and tingling in her right leg. She tried ibuprofen from urgent care with minimal relief. She denies any history of trauma or fall. She reports hypertension as her only significant past medical history and a previous hysterectomy. Allergy: Penicillin (hives). i-Human Patients Academic Team | Full Case Study Including Pathophysiology, Reasoning, and Broader Implications | For Educational Use I-Human Case Study | 66-Year-Old Female with Back Pain | Week #9 5 | P a g e 3 | P a g e SECTION 1: CHIEF COMPLAINT AND HISTORY OF PRESENT ILLNESS (HPI) 1.1 Chief Complaint "My back really hurts." Margaret Collins, a 66-year-old female, presents to the primary care clinic with a chief complaint of low back pain of 4 days duration, which began acutely during a work-related lifting incident. 1.2 History of Present Illness (HPI) — OPQRST Analysis Onset 4 days ago; acute onset while rearranging heavy restaurant tables at work Provocation/Palliation Worsened by movement, walking, and rolling over in bed. Minimal relief with ibuprofen (prescribed by urgent care). No position provides complete relief. Quality Sharp pain in the lower back; shooting, stabbing pain radiating into the right leg Region/Radiation Originates in the lower lumbar region; radiates down the right leg (dermatomal pattern suggestive of L4–L5 or L5–S1 nerve root involvement) Severity 7 out of 10 on numeric pain scale; patient describes as severe and functionally limiting