NURS 6512 Week 9 Human Case Study 2026 | Back Pain
SOAP Note | 55-Year-Old Male | A+ Verified Answers &
Rationales
Case Overview
This case involves a 55-year-old man with worsening lower back pain. It
includes a thorough health assessment, clinical reasoning, differential
diagnoses with explanations, and a management plan based on current
guidelines.
FULL SOAP NOTE
S – Subjective Data
Chief Complaint (CC)
“I have had lower back pain for about 2 weeks.”
History of Present Illness (HPI)
A 55-year-old man reports a 2-week history of lower back pain that started
gradually without any specific injury. The pain is mainly in the lumbar region
and sometimes spreads to the right lower leg, indicating possible nerve
involvement.
Onset: Gradual
Location: Lumbar spine
Duration: 2 weeks
Character: Dull ache with occasional sharp pain
Radiation: Right leg (backside)
, Severity: 6/10
Timing: Worse in the evening and after long sitting
Aggravating Factors: Sitting, bending, lifting
Relieving Factors: Rest, NSAIDs
Associated Symptoms: Tingling in the right leg
Pertinent Negatives: No trauma, no fever, no bowel/bladder problems
Past Medical History (PMH)
Hypertension (well-controlled)
No history of cancer, osteoporosis, or spine issues
Past Surgical History (PSH)
None reported
Medications
Lisinopril 10 mg daily
Ibuprofen as needed
Allergies
No known drug allergies
Family History
Father: Hypertension
Mother: Osteoarthritis
Social History
Occupation: Office worker (sedentary lifestyle)
SOAP Note | 55-Year-Old Male | A+ Verified Answers &
Rationales
Case Overview
This case involves a 55-year-old man with worsening lower back pain. It
includes a thorough health assessment, clinical reasoning, differential
diagnoses with explanations, and a management plan based on current
guidelines.
FULL SOAP NOTE
S – Subjective Data
Chief Complaint (CC)
“I have had lower back pain for about 2 weeks.”
History of Present Illness (HPI)
A 55-year-old man reports a 2-week history of lower back pain that started
gradually without any specific injury. The pain is mainly in the lumbar region
and sometimes spreads to the right lower leg, indicating possible nerve
involvement.
Onset: Gradual
Location: Lumbar spine
Duration: 2 weeks
Character: Dull ache with occasional sharp pain
Radiation: Right leg (backside)
, Severity: 6/10
Timing: Worse in the evening and after long sitting
Aggravating Factors: Sitting, bending, lifting
Relieving Factors: Rest, NSAIDs
Associated Symptoms: Tingling in the right leg
Pertinent Negatives: No trauma, no fever, no bowel/bladder problems
Past Medical History (PMH)
Hypertension (well-controlled)
No history of cancer, osteoporosis, or spine issues
Past Surgical History (PSH)
None reported
Medications
Lisinopril 10 mg daily
Ibuprofen as needed
Allergies
No known drug allergies
Family History
Father: Hypertension
Mother: Osteoarthritis
Social History
Occupation: Office worker (sedentary lifestyle)
