IHUMAN Case Study: Sam Newton – 62-Year-Old Male With Severe
Lower Back Pain | Musculoskeletal Assessment, Differential
Diagnosis, and Management
Comprehensive IHUMAN case study for Sam Newton, a 62-year-old male presenting with severe lower back pain. Includes
detailed SOAP note, musculoskeletal and neurologic assessment, differential diagnosis, conservative treatment plan, and patient
education for nursing, NP, PA, and medical students.
IHUMAN case study Sam Newton
• Sam Newton IHUMAN case
• Severe lower back pain case study
,Patient Information
Name: Sam Newton
Age: 62 years
Sex: Male
Source: Patient
Reliability: Reliable historian
S – Subjective
Chief Complaint (CC):
“My lower back pain is severe.”
History of Present Illness (HPI):
Sam Newton is a 62-year-old male who presents with severe lower back pain that began 4 days ago and has progressively worsened.
The pain is described as sharp, constant, and rated 8/10, localized to the lumbar region, with intermittent radiation into the right
buttock and posterior thigh.
Pain is aggravated by movement, bending, and prolonged standing, and partially relieved by rest. Over-the-counter NSAIDs have
provided minimal relief. He denies any recent trauma but reports lifting heavy boxes prior to symptom onset.
He denies bowel or bladder incontinence, saddle anesthesia, fever, chills, unexplained weight loss, or night sweats. No prior history of
similar severe back pain.
, Associated Symptoms:
• Muscle stiffness
• Limited range of motion
• Difficulty ambulating
Denied Symptoms:
• Numbness or weakness in lower extremities
• Bowel or bladder dysfunction
• Fever or chills
Past Medical History (PMH):
• Hypertension
• Osteoarthritis
Past Surgical History (PSH):
• None
Medications:
• Lisinopril 10 mg PO daily
• Ibuprofen PRN (minimal relief)
Lower Back Pain | Musculoskeletal Assessment, Differential
Diagnosis, and Management
Comprehensive IHUMAN case study for Sam Newton, a 62-year-old male presenting with severe lower back pain. Includes
detailed SOAP note, musculoskeletal and neurologic assessment, differential diagnosis, conservative treatment plan, and patient
education for nursing, NP, PA, and medical students.
IHUMAN case study Sam Newton
• Sam Newton IHUMAN case
• Severe lower back pain case study
,Patient Information
Name: Sam Newton
Age: 62 years
Sex: Male
Source: Patient
Reliability: Reliable historian
S – Subjective
Chief Complaint (CC):
“My lower back pain is severe.”
History of Present Illness (HPI):
Sam Newton is a 62-year-old male who presents with severe lower back pain that began 4 days ago and has progressively worsened.
The pain is described as sharp, constant, and rated 8/10, localized to the lumbar region, with intermittent radiation into the right
buttock and posterior thigh.
Pain is aggravated by movement, bending, and prolonged standing, and partially relieved by rest. Over-the-counter NSAIDs have
provided minimal relief. He denies any recent trauma but reports lifting heavy boxes prior to symptom onset.
He denies bowel or bladder incontinence, saddle anesthesia, fever, chills, unexplained weight loss, or night sweats. No prior history of
similar severe back pain.
, Associated Symptoms:
• Muscle stiffness
• Limited range of motion
• Difficulty ambulating
Denied Symptoms:
• Numbness or weakness in lower extremities
• Bowel or bladder dysfunction
• Fever or chills
Past Medical History (PMH):
• Hypertension
• Osteoarthritis
Past Surgical History (PSH):
• None
Medications:
• Lisinopril 10 mg PO daily
• Ibuprofen PRN (minimal relief)
