I-Human Case Study Week #9: 54-Year-Old Male with Back
Pain In An Outpatient Week 9 Ihuman
,
, In the iHuman Week 9 case study, the patient is a 54-year-old male presenting with chronic
lower back pain. He reports a dull, persistent ache in his lower back that has been worsening
over several months. The pain is exacerbated by physical activity and prolonged standing, and it
interferes with his ability to perform daily tasks. The patient works in a physically demanding
job, which may contribute to his symptoms. (CliffsNotes)
History of Present Illness (HPI):
• Onset: Gradual over several months
• Character: Dull, persistent ache
• Aggravating factors: Physical activity, prolonged standing
• Relieving factors: Rest, over-the-counter analgesics
• Associated symptoms: No numbness, tingling, or bowel/bladder dysfunction reported
Physical Examination Findings:
• Tenderness in the lower lumbar region
• Reduced range of motion in lumbar spine
• Negative straight leg raise test
• No neurological deficits observed
Differential Diagnosis:
• Lumbar strain or sprain
• Degenerative disc disease
• Lumbar spondylosis
• Facet joint osteoarthritis
Management Plan:
• Initiate physical therapy focusing on core strengthening and flexibility
• Prescribe nonsteroidal anti-inflammatory drugs (NSAIDs) for pain management
• Educate the patient on proper body mechanics and ergonomics at work
• Schedule follow-up in 4–6 weeks to assess progress
Pain In An Outpatient Week 9 Ihuman
,
, In the iHuman Week 9 case study, the patient is a 54-year-old male presenting with chronic
lower back pain. He reports a dull, persistent ache in his lower back that has been worsening
over several months. The pain is exacerbated by physical activity and prolonged standing, and it
interferes with his ability to perform daily tasks. The patient works in a physically demanding
job, which may contribute to his symptoms. (CliffsNotes)
History of Present Illness (HPI):
• Onset: Gradual over several months
• Character: Dull, persistent ache
• Aggravating factors: Physical activity, prolonged standing
• Relieving factors: Rest, over-the-counter analgesics
• Associated symptoms: No numbness, tingling, or bowel/bladder dysfunction reported
Physical Examination Findings:
• Tenderness in the lower lumbar region
• Reduced range of motion in lumbar spine
• Negative straight leg raise test
• No neurological deficits observed
Differential Diagnosis:
• Lumbar strain or sprain
• Degenerative disc disease
• Lumbar spondylosis
• Facet joint osteoarthritis
Management Plan:
• Initiate physical therapy focusing on core strengthening and flexibility
• Prescribe nonsteroidal anti-inflammatory drugs (NSAIDs) for pain management
• Educate the patient on proper body mechanics and ergonomics at work
• Schedule follow-up in 4–6 weeks to assess progress
