Gloria Jenkins – I-Human
Patient and Encounter
● Patient: Gloria Jenkins
● Age: 65-year-old female
● Reason for encounter: Acute lower back pain
● Setting: Outpatient primary-care clinic
● Current complaint: Sharp, continuous lower-back pain radiating into the right leg
● Onset: Began suddenly while rearranging/lifting heavy tables at work
● Duration: Approximately 2–4 days depending on case version
● Pain: Approximately 7/10, deep/sharp, continuous
● Radiation: Lower back into the right leg
● Aggravating factors: Movement, lifting, walking, prolonged standing, rolling in bed, working
● Relieving factors: No significant relieving factor reported
● Associated symptoms: Difficulty moving because of pain; neurologic sensory changes in the
right lower extremity
● PMH: Osteoporosis/osteopenia, hypertension, diabetes reported in case materials
● Surgical history: Hysterectomy with oophorectomy for fibroids
● Smoking history: Long-term history of smoking
● Current medications: Calcium and vitamin D twice daily
History
General
● How can I help you today?
● When did the back pain begin?
● What were you doing when the pain started?
● Did the pain begin suddenly or gradually?
● Has the pain improved or worsened since it began?
● Have you experienced this type of pain before?
● How severe is the pain from 0–10?
● Does the pain interfere with sleep or daily activities?
Back Pain
● Where exactly is the pain located?
● Is the pain superficial or deep?
● How would you describe the pain?
● Is it sharp, dull, aching, burning, or stabbing?
● Is the pain constant or intermittent?
● Does bending forward worsen the pain?
● Does sitting worsen the pain?
, ● Does standing or walking for a long time worsen the pain?
● Does lifting make the pain worse?
● Does rolling over in bed worsen the pain?
● Have you tried anything for the pain?
● Does anything relieve the pain?
Radiating/Neurologic Symptoms
● Does the pain radiate anywhere?
● Does it travel down the leg?
● Which leg is affected?
● Any numbness?
● Any tingling?
● Any weakness?
● Any difficulty walking?
● Any difficulty moving the leg?
● Any new weakness in the arms, legs, or face?
● Any changes in sensation?
● Any loss of bowel or bladder control?
● Any saddle numbness?
Red Flags
● Any recent fall or trauma?
● Did you hear or feel a popping sensation?
● Any fever or chills?
● Any unexplained weight loss?
● History of cancer?
● History of spinal disease?
● History of osteoporosis?
● Any history of IV drug use?
● Any recent infection?
● Any history of significant steroid use?
Past History
● Previous episodes of back pain?
● Previous spinal problems?
● History of osteoporosis or osteopenia?
● History of hypertension?
● History of diabetes?
● Previous fractures?
● Previous surgeries?
● Previous hysterectomy?
● Previous oophorectomy?
Patient and Encounter
● Patient: Gloria Jenkins
● Age: 65-year-old female
● Reason for encounter: Acute lower back pain
● Setting: Outpatient primary-care clinic
● Current complaint: Sharp, continuous lower-back pain radiating into the right leg
● Onset: Began suddenly while rearranging/lifting heavy tables at work
● Duration: Approximately 2–4 days depending on case version
● Pain: Approximately 7/10, deep/sharp, continuous
● Radiation: Lower back into the right leg
● Aggravating factors: Movement, lifting, walking, prolonged standing, rolling in bed, working
● Relieving factors: No significant relieving factor reported
● Associated symptoms: Difficulty moving because of pain; neurologic sensory changes in the
right lower extremity
● PMH: Osteoporosis/osteopenia, hypertension, diabetes reported in case materials
● Surgical history: Hysterectomy with oophorectomy for fibroids
● Smoking history: Long-term history of smoking
● Current medications: Calcium and vitamin D twice daily
History
General
● How can I help you today?
● When did the back pain begin?
● What were you doing when the pain started?
● Did the pain begin suddenly or gradually?
● Has the pain improved or worsened since it began?
● Have you experienced this type of pain before?
● How severe is the pain from 0–10?
● Does the pain interfere with sleep or daily activities?
Back Pain
● Where exactly is the pain located?
● Is the pain superficial or deep?
● How would you describe the pain?
● Is it sharp, dull, aching, burning, or stabbing?
● Is the pain constant or intermittent?
● Does bending forward worsen the pain?
● Does sitting worsen the pain?
, ● Does standing or walking for a long time worsen the pain?
● Does lifting make the pain worse?
● Does rolling over in bed worsen the pain?
● Have you tried anything for the pain?
● Does anything relieve the pain?
Radiating/Neurologic Symptoms
● Does the pain radiate anywhere?
● Does it travel down the leg?
● Which leg is affected?
● Any numbness?
● Any tingling?
● Any weakness?
● Any difficulty walking?
● Any difficulty moving the leg?
● Any new weakness in the arms, legs, or face?
● Any changes in sensation?
● Any loss of bowel or bladder control?
● Any saddle numbness?
Red Flags
● Any recent fall or trauma?
● Did you hear or feel a popping sensation?
● Any fever or chills?
● Any unexplained weight loss?
● History of cancer?
● History of spinal disease?
● History of osteoporosis?
● Any history of IV drug use?
● Any recent infection?
● Any history of significant steroid use?
Past History
● Previous episodes of back pain?
● Previous spinal problems?
● History of osteoporosis or osteopenia?
● History of hypertension?
● History of diabetes?
● Previous fractures?
● Previous surgeries?
● Previous hysterectomy?
● Previous oophorectomy?
