Case Study: Severe Atraumatic Lower Back Pain in a 54-Year-Old Male – Diagnosis, Management & Red Flag Review
iHuman Case Study: Severe Atraumatic Lower Back Pain
Patient Details
· Age: 54
· Sex: Male
· Date of Visit: [Insert Date]
· Chief Complaint (CC): "My lower back hurts really badly, and I don't know why."
Subjective
· History of Present Illness (HPI):
o 54-year-old male presents with severe lower back pain that began 5 days ago, without any
trauma or injury.
o Describes the pain as sharp and deep, rated 9/10, located centrally in the lower lumbar
region, with occasional radiation to the left buttock, but not below the knee.
o Reports no specific inciting event (no lifting, fall, or accident).
o Pain is worse with standing, walking, and sitting upright; slightly relieved when lying flat
with knees bent.
o Denies numbness, tingling, weakness, or bowel/bladder incontinence.
o No fever, chills, or weight loss.
o No history of similar pain before.
· Past Medical History:
o Hypertension
o Hyperlipidemia
o No known history of cancer, diabetes, or autoimmune disease.
· Medications:
o Lisinopril 20 mg daily
o Atorvastatin 10 mg nightly
o Occasional NSAIDs (ibuprofen) for joint aches
· Allergies:
o NKDA
· Family History:
o Father: deceased (MI at 68), Mother: alive (HTN, OA)
· Social History:
o Works as a high school teacher, mostly sedentary job
o No tobacco use, drinks alcohol socially
o No recreational drug use
Objective
· Vitals:
o BP: 132/84 mmHg
o HR: 78 bpm
o Temp: 98.6°F (37°C)
o RR: 16
o SpO2: 98% on room air
· General: Alert, appears uncomfortable sitting, frequently shifts position.
· Back Exam:
o Inspection: No bruising, swelling, or deformity
o Palpation: Tenderness over L4–L5 region, paraspinal muscles tight bilaterally
o Range of Motion: Limited flexion and extension due to pain
o Straight Leg Raise: Negative bilaterally
· Neurologic Exam:
o Motor: 5/5 strength in bilateral lower extremities
o Sensory: Intact to light touch in L2–S1 dermatomes
o Reflexes: 2+ patellar and Achilles reflexes bilaterally
· Gait: Slow, slightly antalgic