54 Year Old Patient Cc: Low Back Pain–SEVERE
ATRAUMATIC Lower Back Pain
,
,
, I-human Case – Adult Male With Back Pain (comprehensive Case)
Patient Introduction
Name: Not Disclosed (i-Human Virtual Patient)
Age: 54-year-old male
Height/Weight: 5’10” (178 cm), 155 lb (70.5 kg)
Setting: Outpatient clinic with X-ray, ECG, and laboratory capabilities
Chief Complaint: “My back has been hurting.”
Chief Complaint (CC)
Lower back pain for several days.
History of Present Illness (HPI)
The patient is a 54-year-old male who presents with acute-onset low back pain that began
approximately 5–7 days ago after lifting a heavy object at work. He describes the pain as dull to
sharp, localized to the lumbar region, rated 6/10, worsened by bending and prolonged standing,
and relieved somewhat with rest. He denies radiation of pain to the legs, numbness, tingling,
bowel or bladder dysfunction, fever, chills, unexplained weight loss, or recent trauma. No prior
similar severe episodes reported.
Past Medical History (PMH)
• Hypertension – well controlled
• No history of chronic back disorders
Surgical History
• Denies prior surgeries
Medications
• Lisinopril 10 mg PO daily
• Occasional OTC ibuprofen
ATRAUMATIC Lower Back Pain
,
,
, I-human Case – Adult Male With Back Pain (comprehensive Case)
Patient Introduction
Name: Not Disclosed (i-Human Virtual Patient)
Age: 54-year-old male
Height/Weight: 5’10” (178 cm), 155 lb (70.5 kg)
Setting: Outpatient clinic with X-ray, ECG, and laboratory capabilities
Chief Complaint: “My back has been hurting.”
Chief Complaint (CC)
Lower back pain for several days.
History of Present Illness (HPI)
The patient is a 54-year-old male who presents with acute-onset low back pain that began
approximately 5–7 days ago after lifting a heavy object at work. He describes the pain as dull to
sharp, localized to the lumbar region, rated 6/10, worsened by bending and prolonged standing,
and relieved somewhat with rest. He denies radiation of pain to the legs, numbness, tingling,
bowel or bladder dysfunction, fever, chills, unexplained weight loss, or recent trauma. No prior
similar severe episodes reported.
Past Medical History (PMH)
• Hypertension – well controlled
• No history of chronic back disorders
Surgical History
• Denies prior surgeries
Medications
• Lisinopril 10 mg PO daily
• Occasional OTC ibuprofen
