🦴 Mock Patient Script: Lower Back Pain – Two Standard Cases

Practice clinical reasoning and English skills with two classic cases of lower back pain. One is mechanical and benign, while the other hides a serious pathology.

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🚪 Doorway Information

• Age: 38
• Gender: Male
• Chief Complaint: “My lower back’s been killing me for days.”
• Vital Signs: BP 124/78, HR 84, Temp 36.9°C, RR 14, SpO₂ 99%

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📋 Structured History – Case 1: Lumbar Disc Herniation

• Opening: “It started after I helped move some heavy boxes last week.”
• Onset & Course: “It was sudden and got worse over the next few days. Now the pain shoots down my right leg.”
• Character: “It’s a sharp, electric pain. It gets worse when I cough or sit too long.”
• Functional Impact: “I can’t bend down or even tie my shoes without wincing.”
• Associated Symptoms: “My right foot feels a bit numb. No bowel or bladder issues, though.”
• Red Flags Denied: No fever, no trauma, no cancer history.
• Medications: Ibuprofen as needed
• PMH: None
• SH: Office worker, occasional smoker, no alcohol abuse
• FH: Non-contributory

🩺 Physical Exam Findings

• Antalgic gait
• Positive straight leg raise on the right at 35°
• Decreased ankle reflex on the right
• Mild weakness in right toe extension
• No saddle anesthesia, no anal sphincter tone loss
• Normal vitals, no fever

⚖️ Differential Diagnoses

1. Lumbar disc herniation
   ✔ Shooting leg pain, SLR+, dermatomal numbness
   ❌ No bowel/bladder symptoms (no cauda equina)
2. Lumbar strain
   ✔ History of heavy lifting, localized back pain
   ❌ No leg symptoms, no neuro deficit
3. Piriformis syndrome
   ✔ Sciatica-like symptoms
   ❌ No gluteal pain, SLR aggravates (not relieved)

🗒️ SOAP Note – Case 1

S: 38M with acute low back pain and right leg radiation after lifting. Sharp pain, worse with Valsalva.
O: Vitals stable. SLR + on right, mild weakness and sensory change in L5/S1 distribution.
A: Likely lumbar disc herniation
P: MRI lumbar spine, NSAIDs, short-term rest, PT, consider neuro referral if deficits persist

🧠 Clinical Reflection

This case represents a typical mechanical cause of back pain with radiculopathy. It’s important to distinguish between red flags requiring urgent imaging and benign self-limiting cases.

💡 Clinical Pearls

• A positive straight leg raise test is highly sensitive but not specific
• Cauda equina syndrome must be ruled out in any back pain with bladder/bowel issues
• Most disc herniations improve without surgery

💬 Challenging Questions – Case 1

• Q: “Will this go away on its own, or do I need surgery?”
  A: “Most cases improve without surgery. We’ll start conservative treatment and monitor your progress.”
• Q: “Can I keep working with this pain?”
  A: “Depending on your job, we may need temporary adjustments to avoid worsening your symptoms.”

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🚪 Doorway Information – Case 2

• Age: 80
• Gender: Female
• Chief Complaint: “My back hurts all the time, especially at night.”
• Vital Signs: BP 130/80, HR 88, Temp 37.1°C, RR 16, SpO₂ 97%

📋 Structured History – Case 2: Metastatic Spinal Tumor

• Opening: “My lower back’s been hurting constantly for the past two weeks.”
• Pain Features: “It’s deep, dull, and nothing seems to relieve it. Worse when I lie down.”
• Night Pain: “I wake up from the pain. It’s worse at night. I can’t find a comfortable position.”
• Function: “I have trouble walking. My legs feel weak and wobbly.”
• Systemic Symptoms: “I lost about 4 kg in the past month. I thought it was just aging.”
• History Suggestive: “I had breast cancer 10 years ago. It was treated, but I haven’t had check-ups recently.”
• Medications: Calcium and vitamin D
• PMH: Breast cancer, HTN
• FH: Sister with colon cancer
• SH: Lives alone, widowed

🩺 Physical Exam Findings

• Tenderness over L2-L4 spinous processes
• Decreased strength in bilateral hip flexion (4/5)
• Wide-based gait
• Hyperreflexia in lower limbs
• No fever, no saddle anesthesia
• No anal tone loss

⚖️ Differential Diagnoses

1. Spinal metastasis
   ✔ Night pain, history of breast cancer, weight loss, gait disturbance
   ❌ No systemic fever, but still suspicious
2. Lumbar stenosis
   ✔ Age, gait instability
   ❌ Pain is not position-dependent; worsens at night
3. Compression fracture (osteoporotic)
   ✔ Elderly woman, localized back pain
   ❌ No trauma, more systemic symptoms present

🗒️ SOAP Note – Case 2

S: 80F with persistent low back pain, worse at night, progressive weakness, weight loss.
O: Hyperreflexia, gait abnormality, tenderness over lumbar spine. History of breast CA.
A: Likely spinal metastasis
P: Urgent MRI spine, labs (CBC, Ca, AlkP), oncology consult, consider steroids if spinal cord compression suspected

🧠 Clinical Reflection

Back pain in elderly patients with a history of malignancy requires a high index of suspicion. Night pain and systemic signs are red flags that should not be overlooked.

💡 Clinical Pearls

• Night pain and weight loss should always prompt cancer screening
• History of cancer = imaging required, even if pain seems mechanical
• Spinal cord compression requires urgent intervention

💬 Challenging Questions – Case 2

• Q: “Are you saying my cancer is back?”
  A: “We’re seeing signs that might relate to your previous cancer, but we need imaging to confirm. You’re not alone—we’ll go through this together.”
• Q: “Is this why I’m losing weight and can’t sleep?”
  A: “It could be. We’ll investigate carefully and try to find the cause, including checking if there’s been any cancer recurrence.”

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📚 References

• UpToDate: Low Back Pain in Adults – Evaluation
• BMJ Best Practice: Spinal Metastases
• NEJM. 2016. Disc Herniation – Clinical Approach.