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Background: Direct access to physical therapy care provides patients the opportunity to seek physical therapy consultation as their first point of care. Physical therapists are trained to evaluate patients who report to outpatient clinics using direct access and do so in a manner that determines a patient's appropriateness for physical therapy care or if referral to another healthcare discipline is necessary. The purpose of this case report is to present an example of how obtaining a thorough history along with conducting a detailed examination work together to facilitate accurate and efficient differential diagnosis which allows the provision of high-quality care for a patient presenting to an outpatient clinic using direct access. Case Description: The patient was a 60-year-old male who presented to an outpatient physical therapy clinic using direct access with lower back pain and unilateral lower extremity weakness. Muscle weakness in his right lower extremity caused gait abnormalities and a decrease in his function which led him to seek physical therapy services. Clinical Decision-making Process: Patient symptoms of acute onset unilateral muscle weakness coupled with chronic spinal flexion posture along with an increase in sit-ups completed by the patient per report during the subjective examination pointed the therapist in the direction of lumbar disc herniation as the diagnosis. The differential diagnosis list consisted of disorders of the neuromuscular system that can yield sudden onset of lower extremity muscle weakness. Examination findings revealed neurologic signs and symptoms consistent with a nerve injury affecting the L4 and L5 nerve roots along with a positive straight-leg test which further led the therapist to disc herniation as a diagnosis. The therapist elected to treat the patient with a combination of McKenzie lumbar extension and manual therapy techniques. The patient experienced a reduction in symptoms with lumbar extension exercises which supported the therapist's diagnosis of disc herniation and led to the continuation of treatment with increased intensity of lumbar extension exercises. Discussion: This case highlights physical therapy care as a primary source of care through direct access for a patient with lower back pain. It provides a patient case example of how obtaining a thorough history along with conducting a detailed examination worked together to facilitate accurate and efficient differential diagnosis which allowed the provision of high-quality care for a patient presenting to an outpatient clinic using direct access.