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I HUMAN CASE STUDY FOR A 54 YEARS OLD REASON FOR
ENCOUNTER BACK PAIN WEEK 9|| INCLUDING SOAP NOTE,
HPI, PE, DIFFERENTIAL DIAGNOSIS, AND MANAGEMENT
PLAN|| LOCATION; OUTPATIENT CLINIC WITH X-RAY,
ECG, AND LABORATORY CAPABILITIES LATEST AND
COMPLETE UPDATE GRADED A+
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Patient Profile:
Name: Mr. James Carter
Age: 54 years
Gender: Male
Reason for Encounter: Back Pain
Chief Complaint (CC):
“My lower back has been hurting for about a month now, and it’s starting to get
worse.”
History of Present Illness (HPI):
Mr. Carter, a 54-year-old male, presents with a 4-week history of progressive
lower back pain. He describes the pain as dull, constant, with occasional sharp,
shooting episodes radiating from the lumbar region into his left buttock and
posterior thigh. The discomfort intensifies after prolonged periods of standing,
walking, or sitting, and especially when he tries to lift heavy objects. He reports
moderate relief with nonprescription ibuprofen and lying flat on a firm
surface.
The pain began gradually, without any identifiable trauma or acute incident. He
believes it may be related to his job, which involves lifting and managing
inventory in a warehouse setting. Although the pain is localized to the lower back,
it sometimes radiates along the sciatic pathway, which raises concern for
radicular involvement.
He denies numbness in the groin/perineal area, bowel or bladder incontinence,
fevers, chills, unexplained weight loss, or night sweats, helping to initially rule
out emergent causes such as cauda equina syndrome or spinal malignancy.
Onset: Gradual
Location: Lower back, radiating to left leg
Duration: Persistent for 4 weeks
Character: Dull ache with intermittent sharp, radiating pain
Aggravating factors: Standing, bending, lifting, prolonged sitting
I HUMAN CASE STUDY FOR A 54 YEARS OLD REASON FOR
ENCOUNTER BACK PAIN WEEK 9|| INCLUDING SOAP NOTE,
HPI, PE, DIFFERENTIAL DIAGNOSIS, AND MANAGEMENT
PLAN|| LOCATION; OUTPATIENT CLINIC WITH X-RAY,
ECG, AND LABORATORY CAPABILITIES LATEST AND
COMPLETE UPDATE GRADED A+
, 2|Page
Patient Profile:
Name: Mr. James Carter
Age: 54 years
Gender: Male
Reason for Encounter: Back Pain
Chief Complaint (CC):
“My lower back has been hurting for about a month now, and it’s starting to get
worse.”
History of Present Illness (HPI):
Mr. Carter, a 54-year-old male, presents with a 4-week history of progressive
lower back pain. He describes the pain as dull, constant, with occasional sharp,
shooting episodes radiating from the lumbar region into his left buttock and
posterior thigh. The discomfort intensifies after prolonged periods of standing,
walking, or sitting, and especially when he tries to lift heavy objects. He reports
moderate relief with nonprescription ibuprofen and lying flat on a firm
surface.
The pain began gradually, without any identifiable trauma or acute incident. He
believes it may be related to his job, which involves lifting and managing
inventory in a warehouse setting. Although the pain is localized to the lower back,
it sometimes radiates along the sciatic pathway, which raises concern for
radicular involvement.
He denies numbness in the groin/perineal area, bowel or bladder incontinence,
fevers, chills, unexplained weight loss, or night sweats, helping to initially rule
out emergent causes such as cauda equina syndrome or spinal malignancy.
Onset: Gradual
Location: Lower back, radiating to left leg
Duration: Persistent for 4 weeks
Character: Dull ache with intermittent sharp, radiating pain
Aggravating factors: Standing, bending, lifting, prolonged sitting
