I HUMAN CASE WEEK #9-55-YEAR-OLD-MALE REASON FOR ENCOUNTER: BACK PAIN FULL SOAP NOTE NEWEST CASE 2026

I HUMAN CASE WEEK #9-55-YEAR-OLD-MALE REASON FOR
ENCOUNTER: BACK PAIN FULL SOAP NOTE NEWEST CASE 2026




Patient Information

 Age: 55 years
 Gender: Male

,  Location: Outpatient Clinic (with X-ray, ECG, Lab access)
 Height: 6’10”
 Weight: 210 lbs
 BMI: ~30 (obese




History (i-Human Case – 55-year-old Male, Back Pain)

Chief Complaint (CC)

 “I have lower back pain.”


History of Present Illness (HPI)

 Onset: 1 week ago after lifting a heavy object
 Location: Lower back (lumbar region)
 Duration: Constant since onset
 Character: Dull, aching pain with occasional sharp episodes
 Radiation: Radiates to left buttock and posterior thigh (possible sciatica)
 Severity: 7/10
 Timing: Worse with movement, bending, sitting, and lifting
 Aggravating Factors: Physical activity, prolonged sitting
 Relieving Factors: Rest, NSAIDs (partial relief)
 Associated Symptoms: Muscle stiffness, reduced mobility, mild tingling in
left leg
 Pertinent Negatives (important for scoring):
o No fever or chills
o No weight loss
o No bowel or bladder incontinence
o No saddle anesthesia
o No history of cancer
o No significant trauma (other than lifting strain)