Week 9 I-Human Case Analysis – 66-Year-Old Male
With Lower Back Pain
Advanced Primary Care (Class 6550)
Walden University – Fall 2025 Term
, 1 🩺 I-HUMAN CASE STUDY WEEK 9 – 66-YEAR-OLD
FEMALE WITH BACK PAIN (2025 EXTENDED EDITION)
2 I. Introduction
Back pain is among the most common musculoskeletal complaints in
primary-care and emergency settings. Approximately 80 % of adults
experience at least one episode during their lifetime, with the
incidence increasing with age because of degenerative changes in the
spine. The following case analyzes a 66-year-old woman presenting
with acute lower-back pain. The goal is to evaluate her presentation,
exclude red-flag conditions, determine the underlying etiology, and
construct a safe and evidence-based management plan using the
SOAP format aligned with 2025 clinical-practice standards.
3 II. Chief Complaint (CC)
“My lower back has been hurting for about two weeks.”
4 III. History of Present Illness (HPI)
Mrs. Margaret G., a 66-year-old retired teacher, reports the sudden
onset of dull aching pain in her lower back that began two weeks
ago after she lifted a heavy laundry basket. The pain started
immediately afterward and has gradually worsened. It is localized to
the lumbar region, occasionally radiating into the left buttock but
never below the knee.
She describes the pain as constant, dull, and stiff, rated 7/10, worse
with bending, twisting, prolonged standing, or sitting, and
With Lower Back Pain
Advanced Primary Care (Class 6550)
Walden University – Fall 2025 Term
, 1 🩺 I-HUMAN CASE STUDY WEEK 9 – 66-YEAR-OLD
FEMALE WITH BACK PAIN (2025 EXTENDED EDITION)
2 I. Introduction
Back pain is among the most common musculoskeletal complaints in
primary-care and emergency settings. Approximately 80 % of adults
experience at least one episode during their lifetime, with the
incidence increasing with age because of degenerative changes in the
spine. The following case analyzes a 66-year-old woman presenting
with acute lower-back pain. The goal is to evaluate her presentation,
exclude red-flag conditions, determine the underlying etiology, and
construct a safe and evidence-based management plan using the
SOAP format aligned with 2025 clinical-practice standards.
3 II. Chief Complaint (CC)
“My lower back has been hurting for about two weeks.”
4 III. History of Present Illness (HPI)
Mrs. Margaret G., a 66-year-old retired teacher, reports the sudden
onset of dull aching pain in her lower back that began two weeks
ago after she lifted a heavy laundry basket. The pain started
immediately afterward and has gradually worsened. It is localized to
the lumbar region, occasionally radiating into the left buttock but
never below the knee.
She describes the pain as constant, dull, and stiff, rated 7/10, worse
with bending, twisting, prolonged standing, or sitting, and
