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66 - year-old women ihuman. Reason for encounter
Back Pain. Class 6531.Complete Case Study with
Complete Updated answers with screenshots
2025/2026 66-year-old women ihuman. Reason for
encounter Back Pain. Class 6531(WALDEN
UNIVERSITY)
66 - year-old women ihuman. Reason for encounter Back Pain. Class 6531.Complete Case Study with Complete Updated answers with screenshots 2025/2026 66-year-old women ihuman. Reason for encounter Back Pain. Class 653 1 2025
PATIENT HISTORY
Patient History Identifying Data
- Name: [Typically anonymized in i-Human]
- Age: 66 years old
- Sex: Female
- Ethnicity/Race: [As provided in your simulation]
- Marital Status: Widowed
- Occupation: Retired school teacher
- Living Situation: Lives alone, active in community Chief Complaint (CC) "My lower back has been hurting for a few weeks now." History of Present Illness (HPI) The patient is a 66-year-old woman presenting with lower back pain that began approximately 3 weeks ago. The pain is described as a dull ache in the lumbar region, occasionally sharp when bending or twisting. It is constant but worsens with activity and prolonged standing. She rates the pain 6/10 at rest and up to 8/10 during flare-ups. The pain is slightly relieved with acetaminophen and rest. She denies any recent trauma or injury. No numbness, tingling, leg weakness, or bowel/bladder incontinence. She reports morning stiffness that improves slightly throughout the day. No recent fevers, chills, weight loss, or night sweats.
Past Medical History (PMH)
- Osteoporosis (diagnosed 5 years ago)
- Hypertension
- Hyperlipidemia Surgical History
- Appendectomy (remote, uncomplicated) Medications
- Lisinopril 10 mg daily
- Simvastatin 20 mg nightly
- Calcium 500 mg with Vitamin D twice daily
- Acetaminophen 500 mg as needed for pain (1–2 times daily lately) Allergies
- No known drug allergies (NKDA) Family History
- Father: Deceased at 78 (MI)
- Mother: Deceased at 82 (osteoporosis, hip fracture)
- No family history of cancer or autoimmune disease Social History
- Non-smoker
Here is a well-structured and detailed HPI (History of Present Illness) for a 66-year-old woman presenting with back pain in the i-Human simulation (Class 6531 level): HPI (History of Present Illness) The patient is a 66-year-old woman who presents with a 3-week history of gradually worsening lower back pain. She describes the pain as a dull, constant ache localized to the lower lumbar region , slightly more on the left side. The pain occasionally becomes sharp when she moves, especially during bending, lifting, or prolonged standing. She denies any recent trauma, falls, or lifting injuries. The pain is worse in the morning , associated with stiffness, and improves modestly throughout the day with activity. She rates her pain as 6 out of 10 at rest and up to 8 out of 10 during movement. She has been taking acetaminophen as needed, which provides some relief. She denies any numbness, tingling, leg weakness, or changes in bowel or bladder function. She also denies any recent fevers, chills, night sweats, or unintentional weight loss. Her medical history is significant for osteoporosis , diagnosed 5 years ago, as well as hypertension and hyperlipidemia. She is concerned that her pain could be related to a “bone issue” and reports that similar symptoms led her mother to be diagnosed with a vertebral fracture in her 70s. DIAGNOSIS Based on the clinical presentation of the 66-year-old woman with progressive lower back pain, no trauma, normal neurological exam , and a history of osteoporosis , the most likely primary diagnosis is:
Primary Diagnosis Osteoporotic Vertebral Compression Fracture (VCF) ICD-10 Code: M80.08XA – Age-related osteoporosis with current pathological fracture, vertebra(e), initial encounter Rationale:
- Age >65 and female: High risk for osteoporosis
- Known diagnosis of osteoporosis
- Gradual onset of localized back pain with no trauma
- Pain worse with movement, better with rest
- No neurological deficits (rules out acute disc herniation or spinal cord involvement)
- Family history of osteoporotic fractures
- Imaging (e.g., X-ray or MRI in the simulation) likely confirms compression deformity in a lumbar vertebra Differential Diagnoses to Consider
- Lumbar Strain/Sprain
- Usually after exertion or injury, not common in older adults without trauma
- Degenerative Disc Disease
- Chronic, not typically acutely painful
- Spinal Stenosis
- Associated with neurogenic claudication or leg symptoms
- Metastatic Cancer
- Considered if red flags present (e.g., weight loss, night pain, known cancer history)
- Order/review DEXA scan to assess bone density (if not done within past year)
- Evaluate for secondary causes of osteoporosis (e.g., TSH, PTH, vitamin D level, renal function) 3. Activity & Mobility
- Encourage light activity as tolerated o Avoid prolonged bed rest
- Physical therapy referral o Focus on gentle core/back strengthening, posture, and safe movement training 4. Fall Prevention
- Home safety evaluation: Remove trip hazards, add grab bars if needed
- Assess for visual impairment, hypotension, or balance issues
- Consider referral to a geriatric specialist if multiple risk factors 5. Follow-Up & Monitoring
- Re-evaluate in 2–4 weeks to assess: o Pain level o Functional mobility o Response to medication
- Monitor for signs of progressive neurological compromise (refer for MRI if any appear)
6. Patient Education - Importance of adherence to medications and supplements - Discuss chronic nature of osteoporosis and risk of future fractures - Teach proper body mechanics (avoid bending/lifting, use support cushions, etc.) SOAP NOTE Here is a complete, well-structured SOAP note for the i-Human case of a 66 - year-old woman with back pain , appropriate for your Class 6531 (FNP/graduate nursing level): SOAP Note: 66-Year-Old Female with Back Pain S: Subjective Chief Complaint: "My lower back has been hurting for a few weeks." HPI: 66 - year-old woman presents with a 3-week history of gradually worsening lower back pain , described as a dull ache localized to the lower lumbar area , slightly worse on the left side. Pain occasionally becomes sharp with movement (bending or standing long periods). Pain is 6/10 at rest , up to 8/10 with activity. She denies any trauma or injury. Acetaminophen offers partial relief. Denies numbness, tingling, leg weakness, or bowel/bladder changes. Reports stiffness in the morning. Denies fever, weight loss, or night sweats. PMH:
O: Objective Vital Signs:
- BP: 134/
- HR: 76 bpm
- Temp: 98.7°F
- RR: 16
- SpO₂: 98% on room air General: Alert, cooperative, in mild discomfort when sitting and rising Back Exam:
- Tenderness over L2–L3 vertebrae
- Decreased lumbar flexion due to pain
- No swelling, deformity, or ecchymosis Neuro Exam:
- Strength: 5/5 in all extremities
- Reflexes: 2+ bilaterally
- Sensation intact
- Negative straight leg raise test Imaging:
- Lumbar spine X-ray: L2 vertebral compression fracture
- Labs (CBC, ESR, CRP): Within normal limits A: Assessment Primary Diagnosis:
- Osteoporotic Vertebral Compression Fracture (L2)
o ICD-10: M80.08XA – Age-related osteoporosis with current pathological fracture, vertebrae, initial encounter Differential Diagnoses (ruled out):
- Lumbar strain/sprain
- Spinal stenosis
- Degenerative disc disease
- Malignancy (no red flag symptoms) **P: Plan
- Medications:**
- Acetaminophen 650 mg PO q6h PRN pain
- Consider short-term Tramadol if pain is unmanageable
- Start Alendronate 70 mg PO once weekly
- Continue Calcium 1200 mg/day and Vitamin D 800–1000 IU/day 2. Imaging/Diagnostics:
- Order DEXA scan if not updated in last year
- Monitor symptoms; MRI if neurological signs develop 3. Referrals:
- Physical Therapy for gentle core strengthening and posture support
- Consider Endocrinology for osteoporosis management if non- responsive to first-line therapy 4. Education:
- Discuss osteoporosis, fall prevention, and fracture risk
- Teach proper body mechanics and safe activity practices
- Encourage light activity; avoid prolonged bed rest
Speaker Notes: Patient is a 66-year-old woman with progressive low back pain, no trauma, and a history of osteoporosis. Slide 3: History of Present Illness (HPI) Content:
- Onset: 3 weeks ago, gradual
- Location: Lower lumbar, left-sided
- Quality: Dull ache, occasional sharp pain
- Aggravated by: Movement, prolonged standing
- Relieved by: Rest, acetaminophen
- No numbness, incontinence, or trauma Slide 4: Past Medical, Surgical, Social History Content:
- PMH: Osteoporosis, Hypertension, Hyperlipidemia
- Surgical History: Appendectomy
- Social History: Retired teacher, non-smoker, minimal alcohol Slide 5: Review of Systems (ROS) Content:
- (+) Back pain, stiffness
- (–) Weakness, numbness, weight loss, fever, incontinence
Slide 6: Physical Exam Findings Content:
- Tenderness over L2–L
- Decreased ROM in lumbar spine
- Neuro: Normal reflexes, strength, sensation
- Negative straight leg raise Slide 7: Diagnostic Workup Content:
- X-ray: L2 compression fracture
- CBC, ESR, CRP: Normal
- No MRI needed (no red flags)
- Consider DEXA if outdated Slide 8: Final Diagnosis Content:
- Osteoporotic Vertebral Compression Fracture (VCF)
- ICD-10: M80.08XA
- Likely due to age-related bone loss Slide 9: Differential Diagnoses Content:
- Lumbar strain
- Spinal stenosis
