FOR ENCOUNTER:BACK PAIN NEWEST CASE 2026
, Patient Profile
Age: 66 years
Gender: Female
Location: Outpatient clinic with imaging and lab capability
Height: 4’11” (15h0 cm)
Weight: 105 lbs (47.7 kg)
BMI: 26.2
History (i-Human – 66-year-old Female, Back Pain)
Chief Complaint (CC)
“My lower back has been hurting.”
History of Present Illness (HPI)
Onset: 2 weeks ago (gradual onset; may follow minor activity like bending)
Location: Lower back (lumbar region)
Duration: Persistent, progressively worsening
Character: Deep, aching pain with occasional sharp pain on movement
Radiation: To hips or flanks; no clear leg radiation
Severity: 7/10
Timing: Constant, worse with standing or walking
Aggravating Factors: Movement, bending, prolonged standing
Relieving Factors: Rest, lying down, mild relief with acetaminophen
Associated Symptoms: Stiffness, decreased mobility
Pertinent Negatives (VERY IMPORTANT for scoring):
o No fever or chills