i-Human Case Week #9 | 55-Year-Old Male with Back Pain | Pages 20–30
i-Human Case Study | Week #9
Comprehensive Case: 55-Year-Old Male with Back Pain
Pages 20–30 | Physical Exam · Diagnostics · Differential Diagnosis · Management · Practice Questions
NURS 331 / Med-Surg | i-Human Case Study | Page 1
,i-Human Case Week #9 | 55-Year-Old Male with Back Pain | Pages 20–30
Patient Recap & HPI Summary
This section consolidates all subjective data from the patient interview into a structured clinical picture
before proceeding to the physical examination. All pivotal HPI questions were performed during the i-
Human simulation.
20.1 Patient Demographics
Item Detail
Name Mr. J.T. (55-year-old male)
Height / Weight 5'10" (178 cm) / 245 lb (111.4 kg)
BMI 35.1 kg/m² — Obese Class II
Reason for Encounter Acute back pain — onset 3–4 days ago
Chief Complaint "I must have thrown my back out. The pain is terrible."
Setting i-Human Case Week #9 — Outpatient / Urgent Care
20.2 HPI — OLDCARTS Summary
OLDCARTS Patient Response Clinical Significance i-Human Status
Onset 3–4 days ago; sudden Acute mechanical etiology; ✔ Performed
onset while lifting a classic precipitating event
heavy laundry basket of for lumbar disc herniation
wet clothes
Location Lower back (patient Lumbar spine involvement; ✔ Performed
places palm on lumbar guides imaging level
region, L4-L5 estimated
level)
Duration Constant since onset — Continuous pain suggests ✔ Performed
does not come and go structural pathology (disc
herniation) vs. intermittent
spasm
Character Sharp, stabbing, Mixed nociceptive + ✔ Performed
gnawing; also shooting neuropathic features
down right leg
Aggravating ALL movement: rolling in Pain with movement = ✔ Performed
bed, walking; ibuprofen mechanical; NSAID failure =
not helping may need stronger
analgesia
Relieving Nothing reliably helps Failure to find relief: ✔ Performed
structural cause more likely
than simple strain
NURS 331 / Med-Surg | i-Human Case Study | Page 2
, i-Human Case Week #9 | 55-Year-Old Male with Back Pain | Pages 20–30
Timing Continuous; acute onset Acute onset with mechanism ✔ Performed
with lifting mechanism = disc herniation very likely
Severity 7–10/10; excruciating at High severity warrants ✔ Performed
worst aggressive multimodal pain
management
Radiation Right leg → right thigh → Dermatomal radiculopathy: ✔ Performed
sometimes to foot; L4-L5 or L5-S1 nerve root
shooting pain compression
Associated Right leg tingling + Paresthesia = nerve ✔ Performed
numbness on outside of involvement; dermatomal
right thigh; shooting distribution identifies level
sensation
Sleep Pain disrupts sleep; Mechanical pattern: flat ✔ Performed
worse lying flat worsens disc pressure
▶ Key Point
WORKING DIAGNOSIS: Acute lumbar disc herniation (L4-L5 or L5-S1) with right-sided nerve root
compression causing lumbar radiculopathy.
The combination of lifting mechanism + right leg pain/numbness/weakness + positive SLR is highly predictive.
Priority: Rule out cauda equina syndrome at every assessment (ask about bowel/bladder/saddle sensation).
NURS 331 / Med-Surg | i-Human Case Study | Page 3
i-Human Case Study | Week #9
Comprehensive Case: 55-Year-Old Male with Back Pain
Pages 20–30 | Physical Exam · Diagnostics · Differential Diagnosis · Management · Practice Questions
NURS 331 / Med-Surg | i-Human Case Study | Page 1
,i-Human Case Week #9 | 55-Year-Old Male with Back Pain | Pages 20–30
Patient Recap & HPI Summary
This section consolidates all subjective data from the patient interview into a structured clinical picture
before proceeding to the physical examination. All pivotal HPI questions were performed during the i-
Human simulation.
20.1 Patient Demographics
Item Detail
Name Mr. J.T. (55-year-old male)
Height / Weight 5'10" (178 cm) / 245 lb (111.4 kg)
BMI 35.1 kg/m² — Obese Class II
Reason for Encounter Acute back pain — onset 3–4 days ago
Chief Complaint "I must have thrown my back out. The pain is terrible."
Setting i-Human Case Week #9 — Outpatient / Urgent Care
20.2 HPI — OLDCARTS Summary
OLDCARTS Patient Response Clinical Significance i-Human Status
Onset 3–4 days ago; sudden Acute mechanical etiology; ✔ Performed
onset while lifting a classic precipitating event
heavy laundry basket of for lumbar disc herniation
wet clothes
Location Lower back (patient Lumbar spine involvement; ✔ Performed
places palm on lumbar guides imaging level
region, L4-L5 estimated
level)
Duration Constant since onset — Continuous pain suggests ✔ Performed
does not come and go structural pathology (disc
herniation) vs. intermittent
spasm
Character Sharp, stabbing, Mixed nociceptive + ✔ Performed
gnawing; also shooting neuropathic features
down right leg
Aggravating ALL movement: rolling in Pain with movement = ✔ Performed
bed, walking; ibuprofen mechanical; NSAID failure =
not helping may need stronger
analgesia
Relieving Nothing reliably helps Failure to find relief: ✔ Performed
structural cause more likely
than simple strain
NURS 331 / Med-Surg | i-Human Case Study | Page 2
, i-Human Case Week #9 | 55-Year-Old Male with Back Pain | Pages 20–30
Timing Continuous; acute onset Acute onset with mechanism ✔ Performed
with lifting mechanism = disc herniation very likely
Severity 7–10/10; excruciating at High severity warrants ✔ Performed
worst aggressive multimodal pain
management
Radiation Right leg → right thigh → Dermatomal radiculopathy: ✔ Performed
sometimes to foot; L4-L5 or L5-S1 nerve root
shooting pain compression
Associated Right leg tingling + Paresthesia = nerve ✔ Performed
numbness on outside of involvement; dermatomal
right thigh; shooting distribution identifies level
sensation
Sleep Pain disrupts sleep; Mechanical pattern: flat ✔ Performed
worse lying flat worsens disc pressure
▶ Key Point
WORKING DIAGNOSIS: Acute lumbar disc herniation (L4-L5 or L5-S1) with right-sided nerve root
compression causing lumbar radiculopathy.
The combination of lifting mechanism + right leg pain/numbness/weakness + positive SLR is highly predictive.
Priority: Rule out cauda equina syndrome at every assessment (ask about bowel/bladder/saddle sensation).
NURS 331 / Med-Surg | i-Human Case Study | Page 3
