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2025/2026 Comprehensive ihuman CliniCal Case
analysis and evidenCe-Based nursing management of
ChroniC low BaCk pain in a 54-year-old male: a holistiC
assessment, differential diagnosis, soap
doCumentation, and patient-Centered Care plan
, 2
1. Patient Demographics & Baseline Data
• Patient Name: John S. (Mr. J.S.)
• Age / Gender: 54-year-old male
• Race / Ethnicity: Caucasian
• Occupation: Senior Warehouse Operations Supervisor (18 years; requires heavy lifting
up to 50 lbs, repeated twisting, and prolonged sitting/standing)
• Marital Status: Married (28 years)
• Setting: Outpatient Advanced Practice Nursing / Primary Care Clinic
• Source / Reliability: Patient; reliable historian.
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2. Chief Complaint (CC)
"My lower back has been aching for 6 months, but 3 weeks ago I lifted a heavy crate at work
and severe, electric pain started shooting down my right leg all the way to my big toe."
3. History of Present Illness (HPI)
Mr. J.S. is a 54-year-old male who presents with a 6-month history of dull, non-radiating lower
back pain that acutely escalated 3 weeks ago following an occupational lifting incident (lifting a
~45-50 lb box while twisting).
• Onset: Chronic dull lumbar ache began ~6 months ago. Acute exacerbation with right
lower extremity radiation began 3 weeks ago.
• Location: Lumbar spine (L4–S1 region) radiating through the right buttock, posterior-
lateral thigh, lateral calf, dorsum of the right foot, and into the great toe.
• Duration: Constant lower back ache (4/10 baseline); intermittent to continuous sharp
radicular right leg pain (peaks at 8/10).
• Character / Quality: Lower back pain is a deep, heavy ache. Right leg pain is described as
"sharp, burning, stabbing, and like an electric shock," accompanied by "pins and
needles" (paresthesias).
• Aggravating Factors: Sitting for longer than 15–20 minutes, bending forward, lifting
objects, driving, coughing, sneezing, or straining during bowel movements (positive
Valsalva response).
• Alleviating Factors: Lying flat on his back (supine) on a firm surface with pillows under
his knees, ice packs to the lumbar region, and over-the-counter Ibuprofen 400 mg.
• Radiation: Right lower extremity along the L5 dermatome.
• Timing: Pain is worse in the morning upon waking and after prolonged sitting at work.
2025/2026 Comprehensive ihuman CliniCal Case
analysis and evidenCe-Based nursing management of
ChroniC low BaCk pain in a 54-year-old male: a holistiC
assessment, differential diagnosis, soap
doCumentation, and patient-Centered Care plan
, 2
1. Patient Demographics & Baseline Data
• Patient Name: John S. (Mr. J.S.)
• Age / Gender: 54-year-old male
• Race / Ethnicity: Caucasian
• Occupation: Senior Warehouse Operations Supervisor (18 years; requires heavy lifting
up to 50 lbs, repeated twisting, and prolonged sitting/standing)
• Marital Status: Married (28 years)
• Setting: Outpatient Advanced Practice Nursing / Primary Care Clinic
• Source / Reliability: Patient; reliable historian.
, 3
2. Chief Complaint (CC)
"My lower back has been aching for 6 months, but 3 weeks ago I lifted a heavy crate at work
and severe, electric pain started shooting down my right leg all the way to my big toe."
3. History of Present Illness (HPI)
Mr. J.S. is a 54-year-old male who presents with a 6-month history of dull, non-radiating lower
back pain that acutely escalated 3 weeks ago following an occupational lifting incident (lifting a
~45-50 lb box while twisting).
• Onset: Chronic dull lumbar ache began ~6 months ago. Acute exacerbation with right
lower extremity radiation began 3 weeks ago.
• Location: Lumbar spine (L4–S1 region) radiating through the right buttock, posterior-
lateral thigh, lateral calf, dorsum of the right foot, and into the great toe.
• Duration: Constant lower back ache (4/10 baseline); intermittent to continuous sharp
radicular right leg pain (peaks at 8/10).
• Character / Quality: Lower back pain is a deep, heavy ache. Right leg pain is described as
"sharp, burning, stabbing, and like an electric shock," accompanied by "pins and
needles" (paresthesias).
• Aggravating Factors: Sitting for longer than 15–20 minutes, bending forward, lifting
objects, driving, coughing, sneezing, or straining during bowel movements (positive
Valsalva response).
• Alleviating Factors: Lying flat on his back (supine) on a firm surface with pillows under
his knees, ice packs to the lumbar region, and over-the-counter Ibuprofen 400 mg.
• Radiation: Right lower extremity along the L5 dermatome.
• Timing: Pain is worse in the morning upon waking and after prolonged sitting at work.
