A 42-year-old male presents with lower back pain radiating to his left leg that began after lifting a heavy table one month ago. Examination reveals limited range of motion, pain on palpation of L5, and slightly reduced strength in his left leg. The primary diagnosis is lumbosacral radiculopathy, with differential diagnoses including disc herniation, vertebral osteomyelitis, paraspinal muscle strain, piriformis syndrome, and lumbar stenosis. Further assessment is needed to determine the specific cause and appropriate treatment.

1. Patient Information
FA, 42-year-old Caucasian male
Subjective.
CC
“Lowest back pain for the past month”
HPI:
FA is a 42-year-old Caucasian male who presents to the clinic
due to lower back pain that c has been ongoing for the past one
month. FA stated that his pain started after attempting to lift a
heavy table in his home from one part of the house to another
one month ago. Patient reports that resting and taking Ibuprofen
to reduce the pain, while his pain increases with activity. FA
rates his pain at 5 on the 0-10 pain scale, as aching/dull that
radiates to her left leg intermittently.
Current medications Ibuprofen 600mg as needed for pain.
Allergies:
Denies any allergy.
PMHx:
Up to date to immunization. Last influenza and pneumonia
vaccine was November 2019. No past medical history noted. No
previous hospitalization or blood transfusion.
Soc Hx:
FA owns a local car repair shop. He is married with 2 young
kids 10 and 8 years old. Patient is deeply involved in the local
catholic church and is a choir master. Denies use of illicit drug

2. and tobacco. States he is a social drink and consumes 2-3 beer
weekly. Exercises regularly.
Fam Hx:
Father, Alive 72, HTN.
Mother, Alive 68 Diabetes.
Paternal Grandfather: HTN, deceased at age 78 from stroke.
Paternal Grandmother: Alive, 95, Anxiety.
Maternal Grandfather: Alive, 93 HTN, Hyperlipidemia.
Paternal Grandmother: Alive, 88 Type 11 diabetes (controlled
with diet).
Daughter: No medical history, age 10.
Son: No medical history, age 8.
ROS:
General:
Pt denies fever and fatigue. Denies weight loss.
Neurological:
Pt headache, dizziness, syncope, paralysis, ataxia, numbness or
tingling in the extremities. No change in bowel or bladder
control.
HEET
: Eyes: T denies visual changes. Ears: denies hearing loss.
Nose: Denies rhinorrhea. No hearing loss. Sneezing, runny nose
or sore throat.

3. Throat
: Denies sore throat.
Skin:
Pt denies rash, abrasions, or bruising denies rash.
Cardiovascular:
Pt denies chest pain, chest pressure or chest discomfort.
palpitation, and tachycardia.
Respiratory:
Pt denies SOB, Cough congestion or congestion. Respiratory:
Musculoskeletal:
Reports aching/dull lower back pain. Reports a limited range of
motion with bending. Pain occasionally radiated to left leg.
Objective.
Diagnostic results:
Vitals: T: 98.0, HR: 78, RR: 18, BP: 128/70, O2sat: 98% on
RA. Pain 5/10
General:
Pt is AAOx4. Well-groomed male calm and cooperative Able to
communicate fluently, with a good eye contact. Appears in no
acute distress.
Neurological:
No signs of dizziness, no problems with gait or posture noted.
4/5 strength with dorsiflexion and toe extension in LLE. 5/5
strength with dorsiflexion and toe extension in RLE. No
decreased sensation to BUE and BLE.
HEENT:
EOMI, PERRLA, pupil round and reactive to light, moist

4. mucus membrane noted. No head injury noted, oral mucosa dry.
Skin:
No edema noted on extremities No abrasions, and cyanosis.
Skin taut, non-tenting, and atraumatic.
Cardiovascular:
S1, S2 noted with a regular rhythm. No murmur, gallops, or
extra heart sounds.
Respiratory
: Lungs sound clear on auscultation. No adventitious breath
sounds noted.
Musculoskeletal:
No scoliosis noted. Negative Sciatic Nerve, Negative
Mackiewicz sign in bilateral lower extremifies. Negative
Lasegue’s sign in left lower extremity. Pain noted on palpation
of L5. Patellar reflex 2+ bilaterally. Full range of motion in
torso extension and lateral flexion. Limited range of motion
with flexion and lateral rotation of torso related to pain.
A
ss
Primary Diagnosis:
Lumbosacral Radiculopathy
Differential Diagnoses
Lumbosacral radiculopathy
(Disc herniation):
describes the types of pain caused by compression or irritation
of nerve roots in the lower back, caused by lumbar disc

5. herniation, degeneration of the spinal vertebra, and narrowing
of the foramen from which the nerves exit the spinal canal. L5
is the most common injury in the lumbar spine (Hsu, Armon, &
Levin, 2019). An L5 disc herniation typically presents as back
pain that radiates to the leg and foot (Hsu et al., 2019). In a disc
herniation, the nerve root becomes compressed from cancer,
infection, injuries from falls (Hsu et al., 2019). The straight leg
test is the most helpful assessment tool when assessing for a
disc herniation (Hsu et al., 2019). A magnetic resonance
imaging (MRI) scan is used to diagnose a disc herniation by
evaluating the intraspinal spaces for abnormalities (Hsu et al.,
2019).
Vertebral Osteomyelitis:
is a bone infection usually caused by bacteria. In the spine, it is
often found in the vertebrae, although the infection can spread
into the epidural and intervertebral disc spaces. Osteomyelitis is
rare and most common in young children and the elderly, but it
can occur at any age (McDonald & Peel, 2019). The infection to
the bone could result from surgery or other soft tissue infection
(McDonald & Peel, 2019). Symptoms include pain localized to
the disc that is infected and is aggravated with palpitation or
physical activity (McDonald & Peel, 2019). A computerized
axial tomography (CT scan) is used to diagnose Vertebral
Osteomyelitis, using a guided biopsy of the vertebral disc space
to culture the bacteria (McDonald & Peel, 2019). Treatments of
Vertebral Osteomyelitis include antibiotic therapy for six weeks
(Roblot et al., 2007).
Paraspinal muscle strain:
Is defined as over stretch
i
njury or tear of paraspinal muscles and tendons in the low back.
Muscle strains are common injury (Patricios, 2019).
Overstretching of a muscle leads to a small tear in the tissue
causing a strain (Crowley, n.d.). To assess for such muscle

6. strain is by asking about trauma to the painful area (Patricios,
2019). Symptoms include sudden lower back pain, muscle
spasms, inflammation, bruising, and soreness (Crowley, n.d.).
Most times, treatment is not needed or treatments with rest, ice,
pain medication and physical therapy (Cooper, 1993).
Piriformis syndrome:
Piriformis syndrome is a condition in which
the piriformis muscle, located in the buttock region, spasms and
causes buttock pain. The piriformis muscle can also irritate the
nearby sciatic nerve and cause pain, numbness and tingling
along the back of the leg and into the foot (like sciatic pain).
Piriformis syndrome is marked by hip and gluteal pain
(Boyajian-O’Neill, McClain, Coleman, & Thomas, 2008).
Clinical manifestations include acute back pain for less than
four weeks (Wheeler, Wipf, Staiger, Deyo, & Jarvik, 2019).
Symptoms includes worsened pain after sitting down for about
15 minutes (Boyajian-O’Neill et al., 2008). Assessments
includes inspecting the back and posture, palpating the spine,
performing the straight leg test, and assessing psychological
distress (Waddell’s sign) (Wheeler et al., 2019). Diagnoses are
made through electromyography (EMG) by differentiating
between piriformis syndrome versus disc herniation (Boyajian-
O’Neill et al., 2008).
Lumbar Stenosis:
The
l
umbar spine consists of five vertebrae in the lower part of the
spine, between the ribs and the pelvis. Lumbar spinal stenosis is
a narrowing of the spinal canal, compressing the nerves
traveling through the lower back into the legs. (Ball, Dains,
Flynn, Solomon, & Stewart, 2019). Symptoms include pain with
activities, such as walking or standing. The pain from Lumbar
Stenosis radiates down the leg, slight relief in a sitting position,
and increased pain with prolonged standing/walking (Ball et al.,

7. 2019). To assess, the patient exhibits a forward gait and lower
extremity weakness in progressing lumbar stenosis (Ball et al.,
2019). To diagnose, a radiology imaging (X-ray), CT scan, and
an MRI are used (American Association of Neurological
Surgeons [AANS], n.d.).
Conclusion
According to the scenario presented, the probable nerve that are
involved are L4-S1. The cause could also be from lumbar two,
three, and four (L2,3,4) (Ball, Dains, Flynn, Solomon, &
Stewart, 2019). The straight leg test is used to test for L4-S1
abnormalities (Standford Medicine 25, n.d.). The femoral
stretch test is used to test for L2,3,4 abnormalities (Mackiewicz
sign). Also, using the patient’s history, such as pain onset,
location, duration, character, aggravating and relieving factors
could help in diagnoses (Ball et al., 2019). I chose these 5-
differential diagnosis, disc herniation, vertebral osteomyelitis,
lumbar stenosis, paraspinal muscle strain, and piriformis
syndrome. The assessment and diagnosis of the lower back pain
should involve examination of gait, posture, range of motion,
inspection, and palpation of the painful location (Bratton,
1999). Assessment should include asking the patient to bend
forward in flexion, extension, lateral flexion, and lateral
rotation to evaluate the range of motion and limitation (Bratton,
1999).
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