Low Back Pain with Radiculopathy

Patient presents with complaints of low back pain radiating to the leg, consistent with lumbar radiculopathy.  Onset of symptoms occurred approximately [duration] ago and is described as [quality of pain: e.g., sharp, burning, aching, electric].  The pain is exacerbated by [exacerbating factors: e.g., bending, lifting, sitting, standing] and relieved by [relieving factors: e.g., rest, medication, ice, heat].  The patient reports pain radiating down the [affected leg: right, left] along the [dermatomal distribution: e.g., L5, S1] dermatome.  Associated symptoms include [associated symptoms: e.g., numbness, tingling, weakness, muscle spasms].  Physical examination reveals [positive findings: e.g., positive straight leg raise test, decreased reflexes, muscle weakness, sensory deficits].  Neurological examination indicates [neurological findings: e.g., diminished reflexes, dermatomal sensory loss].  The patient denies [pertinent negatives: e.g., bowel or bladder incontinence, saddle anesthesia].  Differential diagnoses include lumbar disc herniation, spinal stenosis, degenerative disc disease, and facet joint syndrome.  Assessment points to low back pain with radiculopathy, likely secondary to [suspected etiology: e.g., disc herniation].  Plan includes [diagnostic testing: e.g., MRI lumbar spine], [pharmacological treatment: e.g., NSAIDs, muscle relaxants, neuropathic pain medication], [physical therapy: e.g., core strengthening exercises, stretching], and [referral if necessary: e.g., referral to pain management specialist, neurosurgery].  Patient education provided on proper body mechanics, activity modification, and pain management strategies. Follow-up scheduled in [duration] to assess response to treatment.