i-HUMAN CASE STUDY WEEK#9 (54-
YRS-OLD MALE WITH BACK PAIN)
,Patient Introduction
• Patient Name: [Redacted for confidentiality]
• Age/Sex: 54-year-old male
• Chief Complaint (CC): “My lower back has been hurting for the past few weeks.”
• Date of Visit: [Insert date]
• Setting: Outpatient clinic
History of Present Illness (HPI)
Mr. [Redacted] is a 54-year-old male presenting with a 4-week history of lower back pain, gradually
worsening. He describes the pain as dull, aching, and intermittent, located primarily in the lumbar
region, radiating occasionally to the left buttock.
• Onset: Gradual over 4 weeks
• Duration: Persistent, worse in the evenings and after prolonged sitting
• Character: Dull, aching
• Radiation: Occasionally to left buttock, no leg numbness or weakness reported
• Severity: 6/10 on average, increases to 8/10 after physical activity
• Aggravating Factors: Bending, lifting, prolonged sitting
• Relieving Factors: Rest, over-the-counter acetaminophen
• Associated Symptoms: Mild stiffness in the morning, no bowel/bladder changes, no fever, no
numbness, no tingling in the legs
He reports that he recently started a home renovation project, lifting heavy objects, which may have
triggered the pain. No history of trauma, recent infections, or previous back surgeries.
Past Medical History
• Hypertension – diagnosed 5 years ago, controlled with medications
• Hyperlipidemia – diagnosed 3 years ago
• No previous back surgeries or fractures
• No known chronic illnesses affecting musculoskeletal or neurological function
, Medications
• Lisinopril 20 mg daily
• Atorvastatin 20 mg nightly
• Occasional acetaminophen for back pain
Allergies
• No known drug allergies (NKDA)
Family History
• Father: Coronary artery disease
• Mother: Osteoarthritis
• Siblings: Alive, no significant illnesses
Social History
• Works as a construction supervisor
• Non-smoker, drinks alcohol socially (1–2 drinks/week)
• Exercises occasionally (walking, stretching)
• Diet: Balanced, but admits to occasional fast food
Review of Systems (ROS)
General: Denies fever, weight loss, or fatigue
Musculoskeletal: Positive for low back pain and stiffness; denies joint swelling elsewhere
Neurological: Denies numbness, tingling, weakness in legs
GI/GU: Denies changes in bowel or bladder habits
Cardiovascular: Denies chest pain, palpitations
Respiratory: Denies shortness of breath
Other systems: Negative
Physical Examination
Vital Signs:
• BP: 138/84 mmHg
YRS-OLD MALE WITH BACK PAIN)
,Patient Introduction
• Patient Name: [Redacted for confidentiality]
• Age/Sex: 54-year-old male
• Chief Complaint (CC): “My lower back has been hurting for the past few weeks.”
• Date of Visit: [Insert date]
• Setting: Outpatient clinic
History of Present Illness (HPI)
Mr. [Redacted] is a 54-year-old male presenting with a 4-week history of lower back pain, gradually
worsening. He describes the pain as dull, aching, and intermittent, located primarily in the lumbar
region, radiating occasionally to the left buttock.
• Onset: Gradual over 4 weeks
• Duration: Persistent, worse in the evenings and after prolonged sitting
• Character: Dull, aching
• Radiation: Occasionally to left buttock, no leg numbness or weakness reported
• Severity: 6/10 on average, increases to 8/10 after physical activity
• Aggravating Factors: Bending, lifting, prolonged sitting
• Relieving Factors: Rest, over-the-counter acetaminophen
• Associated Symptoms: Mild stiffness in the morning, no bowel/bladder changes, no fever, no
numbness, no tingling in the legs
He reports that he recently started a home renovation project, lifting heavy objects, which may have
triggered the pain. No history of trauma, recent infections, or previous back surgeries.
Past Medical History
• Hypertension – diagnosed 5 years ago, controlled with medications
• Hyperlipidemia – diagnosed 3 years ago
• No previous back surgeries or fractures
• No known chronic illnesses affecting musculoskeletal or neurological function
, Medications
• Lisinopril 20 mg daily
• Atorvastatin 20 mg nightly
• Occasional acetaminophen for back pain
Allergies
• No known drug allergies (NKDA)
Family History
• Father: Coronary artery disease
• Mother: Osteoarthritis
• Siblings: Alive, no significant illnesses
Social History
• Works as a construction supervisor
• Non-smoker, drinks alcohol socially (1–2 drinks/week)
• Exercises occasionally (walking, stretching)
• Diet: Balanced, but admits to occasional fast food
Review of Systems (ROS)
General: Denies fever, weight loss, or fatigue
Musculoskeletal: Positive for low back pain and stiffness; denies joint swelling elsewhere
Neurological: Denies numbness, tingling, weakness in legs
GI/GU: Denies changes in bowel or bladder habits
Cardiovascular: Denies chest pain, palpitations
Respiratory: Denies shortness of breath
Other systems: Negative
Physical Examination
Vital Signs:
• BP: 138/84 mmHg
