I-HUMAN CASE STUDY FLORENCE BLACKMAN, Exams of Nursing

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BACK PAIN WEEK #9 CASE STUDY PRESENT 54

YEARS OLD PATIENT REASON FOR ENCOUNTER;

chronic back pain COURSE 6512 LATEST UPDATE

2025/2026 ACTUAL SCREENSHOT.

Mr. J.P. is a 54-year-old male presenting with a 2-week history of gradually worsening lower back pain. He describes the pain as a dull ache , localized in the lumbar region , with occasional radiation to the left buttock but not below the knee. The pain is worse with prolonged sitting and improves with standing or walking. He denies any trauma, fever, weight loss, night sweats, bowel/bladder incontinence, or weakness/numbness in the legs.

 Onset: 2 weeks ago  Location: Lower back, occasional radiation to left buttock  Duration: Persistent, daily  Character: Dull, aching pain  Aggravating Factors: Sitting, especially at work  Relieving Factors: Standing, light walking, ibuprofen  Severity: Rates pain 6/10 on average, up to 8/10 at worst

PHYSICAL EXAMINATION (PE)

Vital Signs:

 BP: 124/78 mmHg  HR: 68 bpm  Temp: 98.2°F (36.8°C)  RR: 16/min  SpO₂: 98% on room air

General:

 Well-appearing male in no acute distress

Back:

 Inspection: Normal alignment, no deformity or swelling  Palpation: Tenderness over the left paraspinal muscles (L4–L5 level), no vertebral tenderness  Range of motion: Reduced lumbar flexion and extension due to pain

Neurological:

 Straight leg raise: Negative bilaterally  Strength: 5/5 in bilateral lower extremities  Reflexes: Patellar and Achilles reflexes 2+ and symmetric  Sensation: Intact to light touch and pinprick in dermatomal distribution

Gait: Normal

Other Systems: Unremarkable

DIFFERENTIAL DIAGNOSIS

1. Mechanical Low Back Pain (most likely) o Classic presentation with no red flags, localized pain, and normal neurologic exam
2. Lumbar Strain or Sprain o Muscle tenderness and activity-related worsening support this possibility
3. Lumbar Disc Degeneration / Early Disc Herniation o Possible but less likely given absence of leg symptoms or positive straight leg raise
4. Facet Joint Osteoarthritis o More common with aging; may contribute to pain with prolonged sitting
5. Sacroiliac Joint Dysfunction o Less likely but possible given buttock radiation
6. Less Likely / Red Flag Conditions to Rule Out: o Spinal infection (no fever, normal WBC) o Vertebral fracture (no trauma or tenderness) o Malignancy (no weight loss or constitutional symptoms) o Cauda Equina Syndrome (no bowel/bladder dysfunction, no saddle anesthesia)

PATIENT EDUCATION:

 Educated about benign nature of mechanical back pain  Warned about red flag symptoms: worsening numbness, weakness, bladder/bowel changes  Reviewed importance of posture, lumbar support, and physical activity

EXPERT FEEDBACK (From Family Medicine Faculty)

Strengths:

 Thorough history and appropriate ruling out of red flag symptoms  Conservative management aligns well with current clinical guidelines  Avoidance of unnecessary imaging is supported by evidence  Good patient education and use of shared decision-making

Suggestions for Improvement:

 Consider incorporating a pain diagram or functional assessment tool like the Oswestry Disability Index to track progress  Could ask more specifically about psychosocial factors (e.g., stress, job dissatisfaction) which can influence chronicity of back pain  Include documentation of hip and abdominal exam to rule out referred pain sources

Overall Assessment: ✔️ This case reflects a solid, evidence-based approach to common mechanical low back pain in a middle-aged adult without red flags. Management is appropriate and comprehensive.

Let

Case Study: Back Pain in a 54-Year-Old Male

Demographics

 Age: 54 years  Sex: Male  Height: 5'10" (178 cm)  Weight: 155.0 lb (70.0 kg)  BMI: 22.1 (normal range)  Occupation: Accountant  Past Medical History: Hypertension, well-controlled  Medications: Lisinopril 10 mg daily  Social History: Non-smoker, occasional alcohol, no illicit drug use  Family History: Father with history of osteoarthritis; no known malignancies

Reason for Encounter

 Chief Complaint: "I’ve been having lower back pain for the past two weeks.”

HISTORY OF PRESENT ILLNESS (HPI)