A Worked Part IV Case: Low Back Pain

Reading about the method is one thing; watching it run is another. Here's a single Part IV patient station played out end to end — one of the most common presentations you'll see — so you can watch the door note, encounter, disposition, and SOAP note connect into one clean chain.

Step 1 — Turn the door note into a plan

Two minutes, three jobs (station rhythm). First, a working differential: unilateral leg pain worse with sitting and flexion points hard at a lumbar disc herniation with an L5 or S1 radiculopathy. But hold the alternatives — facet-mediated pain, SI joint, and the can't-miss ones: cauda equina, fracture, and non-mechanical causes (vascular, malignancy, infection).

Second, the exam that separates those: a lumbar neuro screen (motor, reflexes, sensory by dermatome), straight-leg raise and its crossed variant, and a red-flag screen. Third, the questions that would change my disposition — which I ask first.

Step 2 — History that hunts for the disposition

In the 14-minute encounter, the first minutes buy the most information. Alongside a focused OPQRST, I go straight for the red flags this presentation demands (why that matters): Any change in bladder or bowel control? Numbness in the saddle region? Progressive weakness in the leg? Fever, night pain, unexplained weight loss? History of cancer? Here, the patient denies all of them — the pain is positional, there's no saddle numbness, no incontinence, no constitutional signs. That's not a formality; it's the answer to “is this mine to treat?”

Step 3 — A focused, narrated exam

Now the discriminating exam, out loud (selecting maneuvers):

• Straight-leg raise, right: positive at ~40°, reproducing his leg pain — not just back pain.
• Neuro screen: mild weakness of great-toe extension on the right, diminished sensation along the lateral leg and dorsal foot — an L5 pattern.
• Reflexes: symmetric; no upper-motor-neuron signs.
• Red-flag exam: normal gait, intact saddle sensation, no midline bony tenderness suggesting fracture.

Every finding is spoken as I go, which both earns the examination-domain points and pre-writes my Objective section.

Step 4 — Commit to a disposition, out loud

The picture is a right L5 radiculopathy, most likely discogenic, with no red flags — a case that can be managed conservatively. That's disposition one: treat in the office, with a plan to reassess and escalate to imaging or referral if there's progressive neuro deficit. I say it in a plain report of findings:

That single paragraph banks points across communication, decision-making, and case management at once.

Step 5 — The SOAP note, under the cap

Six minutes, four fields, each ≤950 characters (how to write it fast). Because you narrated the exam, the note nearly writes itself:

• S: 42M, 3 wks right-sided LBP radiating to lateral leg/foot, worse sitting/flexion. Denies bladder/bowel changes, saddle numbness, progressive weakness, fever, night pain, weight loss, cancer hx.
• O: SLR right + at 40° reproducing leg pain; R great-toe extensor weakness; decreased sensation lateral leg/dorsal foot (L5); reflexes symmetric; gait normal; saddle sensation intact; no midline bony tenderness.
• A: Right L5 radiculopathy, likely discogenic lumbar HNP. No red flags for cauda equina, fracture, or non-mechanical pathology. Disposition: appropriate for conservative in-office care with close reassessment.
• P: Begin conservative care; activity/ergonomic guidance; reassess neuro status each visit. Advanced imaging (MRI) + specialist referral if progressive deficit or failure to improve. Return precautions reviewed (new bowel/bladder or saddle symptoms → urgent care).

What made it a passing station

Not the diagnosis alone — plenty of candidates land “disc.” It was the chain: a planned differential, a red-flag screen that justified the disposition, a focused narrated exam, a spoken report of findings, and a committed note with the disposition in the assessment. That's the whole exam in miniature. Build the chain by running full timed encounters — see the study plan.

This is a teaching example, not medical advice or an official NBCE case — it illustrates the reasoning Part IV rewards.