Presenting Complaints

• 36-year-old female presenting with 2-week history of worsening low back pain.

History of Presenting Complaint

• The patient reports that the pain started gradually about 2 weeks ago after a long day of gardening and yard work.
• The pain is localized to the lower back and radiates down the posterior aspect of her right leg to the knee.
• The pain is worse with standing, walking, and bending forward. It is relieved somewhat with rest and over-the-counter pain medication.
• She denies any recent trauma or injury to the back.
• She reports occasional tingling and numbness in her right leg, but no weakness or bowel/bladder dysfunction.
• She has tried heat, ice, and stretching with minimal relief.

Significant Positives & Negatives For Differentials

Herniated Intervertebral Disc at L4-L5 Level

Positives:

• Radiating leg pain, especially in the posterior aspect of the right leg
• Exacerbation of symptoms with standing, walking, and bending forward
• Occasional tingling and numbness in the right leg

Negatives:

• Absence of significant neurological deficits like weakness or bowel/bladder dysfunction
• Minimal relief with conservative treatments like heat, ice, and stretching

Lumbar Spinal Stenosis

Positives:

• Radiating leg pain, especially with walking or standing
• Occasional tingling and numbness in the leg

Negatives:

• Absence of significant neurological deficits
• Lack of significant relief with rest

Muscle Strain/Spasm

Positives:

• Localized low back pain without significant radiation
• Exacerbation of symptoms with certain movements

Negatives:

• Lack of significant neurological symptoms
• Minimal relief with conservative treatments

Sacroiliac Joint Dysfunction

Positives:

• Localized low back pain without significant radiation
• Exacerbation of symptoms with certain movements

Negatives:

• Lack of significant neurological symptoms
• Minimal relief with conservative treatments

Radiculopathy from Degenerative Disc Disease

Positives:

• Radiating leg pain
• Occasional tingling and numbness in the leg

Negatives:

• Absence of significant neurological deficits
• Lack of significant relief with rest

Past Medical History

• Unremarkable, no prior back injuries or surgeries.
• She had a viral upper respiratory infection about 1 month ago that has since resolved.

Drug/Medication History

• Takes ibuprofen as needed for back pain
• No other regular medications

Social History

• Works as an office administrator, spends most of the day sitting at a desk
• Enjoys gardening and yard work on the weekends
• Non-smoker, occasional social drinker

Family History

• No family history of back problems or neurological disorders

Systems Review

• Positive for low back pain radiating to right leg
• Positive for occasional right leg tingling/numbness
• Negative for fever, chills, unexplained weight loss, bowel/bladder dysfunction

Ideas, Concerns & Expectations

• The patient is concerned that she may have injured her back from the gardening and is worried it may be something serious.
• She expects the doctor to perform a thorough examination and provide a diagnosis and treatment plan.

Case Presentation

Based on the patient's history, physical examination findings, and the analysis of the key positives and negatives for each differential diagnosis, the most likely diagnosis is a herniated intervertebral disc at the L4-L5 level. The radiating leg pain, exacerbation of symptoms with certain movements, and occasional neurological symptoms are highly suggestive of a disc herniation. While other conditions like spinal stenosis and muscle strain cannot be completely ruled out, the combination of this patient's presentation points more towards a disc herniation as the primary cause of her low back and leg pain.