DOI: 9/20/2015. Patient is a 33-year-old female certified nursing assistant who sustained a work-related injury when she felt pain in her left knee while transferring a patient. As per OMNI entry, she was initially diagnosed with mild left lateral disc protrusion.
Electrodiagnostic study done on 03/31/16 showed no clear evidence of all acute lumbar radiculopathy. The patient was unable to provide active muscular contraction during the needle EMG evaluation of the left extensor hallucis longus and flexor digitorum longus. As such, a chronic left L5 radiculopathy cannot be ruled out. Correlation with lumbar imaging is advised.
MRI of the lumbar spine obtained on 03/31/16 revealed a mild left lateral disc protrusion at L4-5 which causes a …show more content…
Tye, the patient presented with left low back pain with paresthesias and numbness. Pain radiates to the left lower leg (numbness and parethesias). Left lower leg is getting worse. Of note, patient has paralysis of the left lower leg since the last visit. Medication history includes Tylenol with codeine#3, 1-2 tablet at bedtime. On examination of the spine, midline lumbosacral spine tenderness is demonstrated. Palpation/compression of the sacroiliac joints are tender. Supine straight leg raise reproduces leg pain. Decreased or painful forward flexion is demonstrated and patient arises abnormally. Step length of gait is decreased bilaterally. Walking mechanics shows minor deviation. There is a “studder” with the left foot when moving …show more content…
Patient still has paresthesias, but improving. Patient is limping again. Patient has bilateral shaking legs, uncontrollably. Muscle strength testing and tones reveals 1-/5 of the left tibialis anterior and left gastrocsoleus. There is spasticity of the muscle to resistance.
It was noted that the patient appears to be doing better than the last visit and is no longer moving while seated. Assessments include low back pain and transient weakness of the left lower extremity. Norco is restarted 5/325 mg ½ tablet three times daily as needed, #63.
Per the medical report dated 11/23/16 by Dr. Tate, it was noted that since her last her visit of 9/8/16, she has had increase in pain, so that she is now back on Norco 5/325 mg, a half pill at a time, for a total of two pills during the day as well as Tylenol No. 3 at night. She no longer takes the tramadol. She still has her left extensor hallucis longus weakness, but it has improved since the last examination. She has no significant lumbar paravertebral muscle spasm, but more lightness across the low back. She has the occasional stress urinary incontinence; however, she has had two children by vaginal birth.
Plan is to proceed with lumbar epidural steroid block #2 with Dr. Lal in
Electrodiagnostic study done on 03/31/16 showed no clear evidence of all acute lumbar radiculopathy. The patient was unable to provide active muscular contraction during the needle EMG evaluation of the left extensor hallucis longus and flexor digitorum longus. As such, a chronic left L5 radiculopathy cannot be ruled out. Correlation with lumbar imaging is advised.
MRI of the lumbar spine obtained on 03/31/16 revealed a mild left lateral disc protrusion at L4-5 which causes a …show more content…
Tye, the patient presented with left low back pain with paresthesias and numbness. Pain radiates to the left lower leg (numbness and parethesias). Left lower leg is getting worse. Of note, patient has paralysis of the left lower leg since the last visit. Medication history includes Tylenol with codeine#3, 1-2 tablet at bedtime. On examination of the spine, midline lumbosacral spine tenderness is demonstrated. Palpation/compression of the sacroiliac joints are tender. Supine straight leg raise reproduces leg pain. Decreased or painful forward flexion is demonstrated and patient arises abnormally. Step length of gait is decreased bilaterally. Walking mechanics shows minor deviation. There is a “studder” with the left foot when moving …show more content…
Patient still has paresthesias, but improving. Patient is limping again. Patient has bilateral shaking legs, uncontrollably. Muscle strength testing and tones reveals 1-/5 of the left tibialis anterior and left gastrocsoleus. There is spasticity of the muscle to resistance.
It was noted that the patient appears to be doing better than the last visit and is no longer moving while seated. Assessments include low back pain and transient weakness of the left lower extremity. Norco is restarted 5/325 mg ½ tablet three times daily as needed, #63.
Per the medical report dated 11/23/16 by Dr. Tate, it was noted that since her last her visit of 9/8/16, she has had increase in pain, so that she is now back on Norco 5/325 mg, a half pill at a time, for a total of two pills during the day as well as Tylenol No. 3 at night. She no longer takes the tramadol. She still has her left extensor hallucis longus weakness, but it has improved since the last examination. She has no significant lumbar paravertebral muscle spasm, but more lightness across the low back. She has the occasional stress urinary incontinence; however, she has had two children by vaginal birth.
Plan is to proceed with lumbar epidural steroid block #2 with Dr. Lal in