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I-HUMAN CASE STUDY OF A 54
YEARS OLD MALE WITH BACK PAIN
CASE ANALYSIS WEEK #9 CLASS
6451| INCLUDES HPI, PE,
DIFFERENTIAL DIAGNOSIS, AND
MANAGEMENT PLAN
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i-Human Case Study: 54-Year-Old Male with Back Pain
Course: NURS 6451 – Advanced Practice Assessment
Week 9 Assignment
Reason for Encounter: Back Pain
1. Chief Complaint (CC)
“I’ve had lower back pain for about a week, and it’s getting worse.”
2. History of Present Illness (HPI)
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Mr. J.T. is a 54-year-old male presenting with progressive lower back pain for 7 days. The pain
began after lifting heavy boxes at work. He describes it as a dull, aching pain localized to the
lumbar region, occasionally radiating to the right buttock but not below the knee. Pain worsens
with bending, twisting, or prolonged sitting and improves slightly with rest and heat.
He denies any numbness, tingling, weakness, bowel or bladder incontinence, or saddle
anesthesia. No recent trauma, fever, or weight loss reported. He rates the pain 7/10 in severity.
He has tried over-the-counter ibuprofen with partial relief.
Associated symptoms: mild stiffness in the morning, improving with movement.
No systemic symptoms such as fever, chills, or night sweats.
3. Past Medical / Surgical / Family / Social History
Medical history: Mild hypertension, well controlled on lisinopril 10 mg daily.
Surgical history: Appendectomy at age 20.
Family history: Father with osteoarthritis; mother with type 2 diabetes.
Social history: Works as a warehouse supervisor (physically active job). No smoking,
occasional alcohol (1–2 beers/week). No recreational drug use. Sleeps 6–7 hours per
night.
4. Review of Systems (ROS)
General: Denies fever, chills, weight loss, or fatigue.
Musculoskeletal: Reports lumbar pain and stiffness; denies joint swelling or redness.
Neurologic: Denies numbness, tingling, weakness, or gait disturbance.
Genitourinary: No urinary retention or incontinence.
Gastrointestinal: No bowel changes or abdominal pain.
Cardiac/Respiratory: Denies chest pain, dyspnea, or cough.
I-HUMAN CASE STUDY OF A 54
YEARS OLD MALE WITH BACK PAIN
CASE ANALYSIS WEEK #9 CLASS
6451| INCLUDES HPI, PE,
DIFFERENTIAL DIAGNOSIS, AND
MANAGEMENT PLAN
,2|Page
i-Human Case Study: 54-Year-Old Male with Back Pain
Course: NURS 6451 – Advanced Practice Assessment
Week 9 Assignment
Reason for Encounter: Back Pain
1. Chief Complaint (CC)
“I’ve had lower back pain for about a week, and it’s getting worse.”
2. History of Present Illness (HPI)
, 3|Page
Mr. J.T. is a 54-year-old male presenting with progressive lower back pain for 7 days. The pain
began after lifting heavy boxes at work. He describes it as a dull, aching pain localized to the
lumbar region, occasionally radiating to the right buttock but not below the knee. Pain worsens
with bending, twisting, or prolonged sitting and improves slightly with rest and heat.
He denies any numbness, tingling, weakness, bowel or bladder incontinence, or saddle
anesthesia. No recent trauma, fever, or weight loss reported. He rates the pain 7/10 in severity.
He has tried over-the-counter ibuprofen with partial relief.
Associated symptoms: mild stiffness in the morning, improving with movement.
No systemic symptoms such as fever, chills, or night sweats.
3. Past Medical / Surgical / Family / Social History
Medical history: Mild hypertension, well controlled on lisinopril 10 mg daily.
Surgical history: Appendectomy at age 20.
Family history: Father with osteoarthritis; mother with type 2 diabetes.
Social history: Works as a warehouse supervisor (physically active job). No smoking,
occasional alcohol (1–2 beers/week). No recreational drug use. Sleeps 6–7 hours per
night.
4. Review of Systems (ROS)
General: Denies fever, chills, weight loss, or fatigue.
Musculoskeletal: Reports lumbar pain and stiffness; denies joint swelling or redness.
Neurologic: Denies numbness, tingling, weakness, or gait disturbance.
Genitourinary: No urinary retention or incontinence.
Gastrointestinal: No bowel changes or abdominal pain.
Cardiac/Respiratory: Denies chest pain, dyspnea, or cough.
