i-Human Case Study Week #9: 66-Year-Old Female with Back Pain –
Complete SOAP Note, H&P, Differential Diagnosis & Evidence-Based
Management | Walden University Nursing 2026
i-Human Case Week #9: 66-Year-Old Female with Back Pain |
Complete SOAP Note, H&P, Differential Diagnosis, Labs &
Management | 2026
Premium
Page 1 of 11
, iHuman Case Study • SOAP & Care Plan
Patient Information
Field Value
Patient Name Not specified
Age 66 years old
Sex Female
Ethnicity Not specified
Height 4' 11" (150 cm)
Weight 105.0 lb (47.7 kg)
Setting Outpatient clinic with x-ray, ECG, and laboratory capabilities
Source of Information Not specified
Page 2 of 11
, Patient Demographics & Identifying Data
The patient is a 66-year-old female presenting to an outpatient clinic with a
chief complaint of back pain. Her reported height is 4 feet 11 inches (150 cm)
and her weight is 105.0 pounds (47.7 kg). This gives her a Body Mass Index
(BMI) of approximately 21.4 kg/m², which falls within the normal weight range.
Her age places her in a demographic where conditions such as osteoporosis,
degenerative disc disease, and various forms of arthritis are more prevalent,
all of which can contribute significantly to back pain. The outpatient clinic
setting, equipped with X-ray, ECG, and laboratory capabilities, suggests that
initial diagnostic workup can be performed on-site, which is beneficial for
prompt assessment and management of her condition. The patient's
identifying data, while limited to age, sex, height, and weight, provides a
foundational understanding of her physical characteristics, which will be
crucial in interpreting her symptoms and physical examination findings.
Further demographic information, such as ethnicity, marital status, and
occupation, would provide additional context but are not available at this time.
The absence of a specified name or other personal identifiers ensures patient
privacy in this case study.
Chief Complaint (CC)
The patient's chief complaint is back pain. This is a very common presentation
in primary care and emergency settings, particularly in older adults. Back pain
can range from acute, self-limiting musculoskeletal strain to chronic,
debilitating conditions, and in some cases, can be indicative of more serious
underlying pathology such as vertebral fractures, spinal stenosis, infection, or
malignancy. Given the patient's age of 66, it is imperative to consider age-
related degenerative changes as a primary cause, but also to rule out red flag
symptoms that might suggest a more urgent or severe etiology. The nature,
Page 3 of 11
Complete SOAP Note, H&P, Differential Diagnosis & Evidence-Based
Management | Walden University Nursing 2026
i-Human Case Week #9: 66-Year-Old Female with Back Pain |
Complete SOAP Note, H&P, Differential Diagnosis, Labs &
Management | 2026
Premium
Page 1 of 11
, iHuman Case Study • SOAP & Care Plan
Patient Information
Field Value
Patient Name Not specified
Age 66 years old
Sex Female
Ethnicity Not specified
Height 4' 11" (150 cm)
Weight 105.0 lb (47.7 kg)
Setting Outpatient clinic with x-ray, ECG, and laboratory capabilities
Source of Information Not specified
Page 2 of 11
, Patient Demographics & Identifying Data
The patient is a 66-year-old female presenting to an outpatient clinic with a
chief complaint of back pain. Her reported height is 4 feet 11 inches (150 cm)
and her weight is 105.0 pounds (47.7 kg). This gives her a Body Mass Index
(BMI) of approximately 21.4 kg/m², which falls within the normal weight range.
Her age places her in a demographic where conditions such as osteoporosis,
degenerative disc disease, and various forms of arthritis are more prevalent,
all of which can contribute significantly to back pain. The outpatient clinic
setting, equipped with X-ray, ECG, and laboratory capabilities, suggests that
initial diagnostic workup can be performed on-site, which is beneficial for
prompt assessment and management of her condition. The patient's
identifying data, while limited to age, sex, height, and weight, provides a
foundational understanding of her physical characteristics, which will be
crucial in interpreting her symptoms and physical examination findings.
Further demographic information, such as ethnicity, marital status, and
occupation, would provide additional context but are not available at this time.
The absence of a specified name or other personal identifiers ensures patient
privacy in this case study.
Chief Complaint (CC)
The patient's chief complaint is back pain. This is a very common presentation
in primary care and emergency settings, particularly in older adults. Back pain
can range from acute, self-limiting musculoskeletal strain to chronic,
debilitating conditions, and in some cases, can be indicative of more serious
underlying pathology such as vertebral fractures, spinal stenosis, infection, or
malignancy. Given the patient's age of 66, it is imperative to consider age-
related degenerative changes as a primary cause, but also to rule out red flag
symptoms that might suggest a more urgent or severe etiology. The nature,
Page 3 of 11
