PRESENTING WITH BACK PAIN AT OUTPATIENT CLINIC
UTILIZING SYSTEMATIC HISTORY-DRIVEN DIAGNOSTIC
REASONING, COMPREHENSIVE PHYSICAL ASSESSMENT,
DIFFERENTIAL DEVELOPMENT, I AND EVIDENCE-BASED
MANAGEMENT IN A SIMULATED CLINICAL EDUCATIONAL
SETTING
,PATIENT INFORMATION
Age: 66 years
Sex: Female
Height: 5′3″ (160 cm)
Weight: 158 lb (71.7 kg)
Location: Outpatient clinic
Reason for Encounter: Back pain
Explanation: The patient is a 66-year-old female presenting to the outpatient clinic with
complaints of persistent lower back pain that has progressively worsened, affecting mobility and
daily activities.
, REASON FOR ENCOUNTER
Category Details
Encounter Type Outpatient clinic visit
Chief Complaint Back pain
Duration 3 weeks
Frequency Constant, worsening
Associated Symptoms Stiffness, limited mobility, mild radiation to legs
Aggravating Factors Movement, prolonged standing, bending
Relieving Factors Rest, mild relief with analgesics
Systemic Symptoms Denies fever, weight loss, bowel/bladder changes
Patient Goals Pain relief and restoration of function
Explanation: The patient presents with subacute lower back pain of increasing severity,
interfering with daily functioning and raising concern for musculoskeletal or degenerative spinal
pathology.