I-HUMAN WEEK #9 CASE STUDY** BACK PAIN IN A
55-YEAR-OLD MALE**FULL CLINICAL WORKUP •
SOAP DOCUMENTATION • DIFFERENTIAL
DIAGNOSIS • LABS • IMAGING • MANAGEMENT
STRATEGY**2026–2027 ACADEMIC YEAR**
# SECTION 1: CASE PRESENTATION & CHIEF COMPLAINT
**Chief Complaint:**
*“I’ve had this nagging pain in my lower back for the past 6 weeks. It’s
getting worse, and now it’s shooting down my right leg.”*
,**Demographics:**
- Age: 55 years
- Sex: Male
- Occupation: Construction worker (heavy lifting)
- BMI: 31 (obese class I)
**Vital Signs (initial triage):**
- BP: 138/86 mmHg
- HR: 88 bpm
- RR: 16/min
- Temp: 37.1°C (98.8°F)
- SpO2: 98% on room air
**Red Flags Screening (Negative unless noted):**
- No fever, chills, night sweats
- No unexplained weight loss
- No bladder or bowel incontinence
- No saddle anesthesia
- No recent trauma
- No history of cancer
---
, # SECTION 2: HISTORY OF PRESENT ILLNESS (HPI)
**Onset:**
Gradual onset 6 weeks ago after lifting a heavy beam at work. Initially
thought it was muscle strain.
**Location:**
Low back (L5–S1 region) with right-sided radicular pain down posterior
thigh and lateral calf to the lateral foot (great toe area).
**Quality:**
Dull ache in back (3/10) with intermittent sharp, electric-shock-like pain
down the leg (7/10). Numbness and tingling in right great toe.
**Severity:**
Worsening over past 2 weeks. Now limits walking >10 minutes and
standing >5 minutes.
**Timing:**
Worse in morning (stiffness) and after prolonged sitting. Improved with
lying down, bending knees, or walking bent forward.
55-YEAR-OLD MALE**FULL CLINICAL WORKUP •
SOAP DOCUMENTATION • DIFFERENTIAL
DIAGNOSIS • LABS • IMAGING • MANAGEMENT
STRATEGY**2026–2027 ACADEMIC YEAR**
# SECTION 1: CASE PRESENTATION & CHIEF COMPLAINT
**Chief Complaint:**
*“I’ve had this nagging pain in my lower back for the past 6 weeks. It’s
getting worse, and now it’s shooting down my right leg.”*
,**Demographics:**
- Age: 55 years
- Sex: Male
- Occupation: Construction worker (heavy lifting)
- BMI: 31 (obese class I)
**Vital Signs (initial triage):**
- BP: 138/86 mmHg
- HR: 88 bpm
- RR: 16/min
- Temp: 37.1°C (98.8°F)
- SpO2: 98% on room air
**Red Flags Screening (Negative unless noted):**
- No fever, chills, night sweats
- No unexplained weight loss
- No bladder or bowel incontinence
- No saddle anesthesia
- No recent trauma
- No history of cancer
---
, # SECTION 2: HISTORY OF PRESENT ILLNESS (HPI)
**Onset:**
Gradual onset 6 weeks ago after lifting a heavy beam at work. Initially
thought it was muscle strain.
**Location:**
Low back (L5–S1 region) with right-sided radicular pain down posterior
thigh and lateral calf to the lateral foot (great toe area).
**Quality:**
Dull ache in back (3/10) with intermittent sharp, electric-shock-like pain
down the leg (7/10). Numbness and tingling in right great toe.
**Severity:**
Worsening over past 2 weeks. Now limits walking >10 minutes and
standing >5 minutes.
**Timing:**
Worse in morning (stiffness) and after prolonged sitting. Improved with
lying down, bending knees, or walking bent forward.
