MEDICAL RECORD SERVICE TREATMENT PLAN Department of Veterans Affairs
VA Palo Health Care System - Palo Alto Division Physical Medicine and Rehabilitation Service (117) Electrodiagnostic Medicine Clinic (650) 493-5000 Ext. 65801 EMG/NCS REPORT
PATIENT: Smith, Mary SSN: 555-55-5555 DATE: 02/22/07 REFERRING PHYSICIAN: Dr. DHIRUJ KIRPALANI REASON FOR REFERRAL: Rule out left leg radiculopathy HISTORY: The patient is a 45-year-old woman with a 20-year history of low back pain that is constant, stable, sharp in character, 6/10 in intensity, with radiation down her left leg to her toes. She notes no alleviating factors and her left leg pain limits his walking up to 1 block, standing to 15 minutes, and carrying 20 pounds. Her pain is 50% in her back and 50% in her left leg. She also complains of numbness and tingling on the soles of her feet, which began several years after onset of her back pain. She had 3 previous epidural injections in Seattle, Washington (not done under fluoroscopy), which provided no relief. IMAGING STUDIES: MRI Lumbar Spine (8/29/01) Impression: 1. MILD TO MODERATE DEGENERATIVE DISC DISEASE WITH A BROAD BASED DISC BULGE AT L5/S1 CAUSING MILD TO MODERATE NEURAL NARROWING ON THE RIGHT AND MILD NEURAL FORAMINAL NARROWING ON THE LEFT. 2. THERE IS NO DISC HERNIATION OR PROTRUSION. 3. INCIDENTAL NOTE OF HEMIANGIOMAS IN THE L3 VERTEBRAL BODY AND THE L1 PEDICLE ON THE RIGHT. XR L-spine (6/17/05) Impression: Normal lumbar spine. Minimal levoscoliosis is positional ALLERGIES: NKDA PMH: plantar faciitis, chondromalacia, sleep apnea, migraines SOCIAL HISTORY: No drinking or smoking history, she currently works in a warehouse doing desk work for the past several months, she was previously lifting computers and monitors at work for several years. MEDICATIONS: Metamucil, naproxen PERTINENT PHYSICAL FINDINGS: Temperature: L ankle 28.8 C Distal articular tenderness: None. Allodynia: None. Sensory: Intact to light touch and pin-prick in the L2-S1 dermatomes bilaterally. EDB Atrophy: Negative bilaterally. Straight Leg Raise: Negative bilaterally Femoral Stretch Test: Negative bilaterally. SIGNATURE/TITLE OF PRACTITIONER DATE 3/22/06
Enter in space below - PATIENT IDENTIFICATION - Treating Facility - Ward No. Date
NAME: Smith, Mary MEDICAL RECORD SSN: 555-55-5555 SERVICE TREATMENT PLAN
Automated VA Form 10-0043a MEDICAL RECORD SERVICE TREATMENT PLAN Department of Veterans Affairs
Manual muscle testing: Hip Knee Knee Dorsi Flex EHL Plantar Flexion Flex Ext Flex Right 4* 4* 4* 4* 4* 4* Left 4* 4* 4* 4* 4* 4* *: pain limited, EHL: extensor hallucis longus
Muscle stretch reflexes Patella Medial Hamstring Ankle Jerk Left 2 0 2 Right 2 0 2
Circumferences Thigh Calf Right (cm) 58 41 Left (cm) 56 41
RESULTS: NERVE CONDUCTION STUDIES: Motor Nerve Conduction: Nerve and Site Latency Amplitude Segment Latency Difference Distance Conduction Velocity Peroneal.L Ankle 4.2 ms 8.1 mV Extensor digitorum brevis-Ankle 4.2 ms 80 mm m/s Fi bula (head) 9.8 ms 8.2 mV Ankle-Fibula (head) 5.6 ms 300 mm 54 m/s Tibial.L Ankle 4.7 ms 16.7 mV Abductor hallucis-Ankle 4.7 ms 80 mm m/s Popliteal fossa 11.3 ms 16.2 mV Ankle-Popliteal fossa 6 .6 ms 330 mm 50 m/s Sensory Nerve Conduction: Nerve and Site Onset Latency Peak Latency Amplitude Segment Latency Difference Distance Conduction Velocity Sural.L Lower leg 3.3 ms 4.0 ms 11 uV Ankle-Lower leg 3.3 ms mm m/s Nerve conduction studies in the left lower extremity were normal.
SIGNATURE/TITLE OF PRACTITIONER DATE 3/22/06
Enter in space below - PATIENT IDENTIFICATION - Treating Facility - Ward No. Date
NAME: Smith, Mary MEDICAL RECORD SSN: 555-55-5555 SERVICE TREATMENT PLAN
Automated VA Form 10-0043a MEDICAL RECORD SERVICE TREATMENT PLAN Department of Veterans Affairs
Needle EMG Examination: Insertional Spontaneous Activity Volitional MUAPs Muscle Insertional Fibs + Wave Fasc Other Durati on Amplitude Poly Recruitment Tibialis anterior.L Normal None None None Normal Normal None No rmal Gastrocnemius (Medial head).L Normal None None None Normal Normal None Normal Vastus medialis.L Normal None None None Normal Normal None Normal Biceps femoris (long head).L Nor mal None None None Normal Normal None Normal Gluteus minimus.L Normal None None None No rmal Normal None Normal L4 paraspinal.L Normal None None None Normal Normal None Normal L 5 paraspinal.L Normal None None None Normal Normal None Normal A disposable monopolar needle electrode was used to study selected muscles in the left lower extremity, including: left tibialis anterior, medial head of the gastrocnemius, gluteus minimus, vastus medialis, biceps femoris long head, L4 paraspinal, and L5 paraspinal. All muscles tested showed normal insertional activity and no abnormal spontaneous activity Motor unit action potentials (MUAP) were normal for amplitude, duration, configuration, and recruitment.
IMPRESSION: Normal Study 1. There is no electrodiagnostic evidence of a left lumbar radiculopathy.
PLAN: 1. The findings were explained to the patient. 2. We scheduled the patient for a caudal epidural steroid injection of her lumbar spine 4/21/06. 3. We consulted physical therapy in Monterey and pool therapy in Palo Alto for lumbar strengthening and stretching exercises.
______Wade Kingery, M.D. Jane Johnson, MD Attending in PM&R Resident in PM&R
SIGNATURE/TITLE OF PRACTITIONER DATE 3/22/06
Enter in space below - PATIENT IDENTIFICATION - Treating Facility - Ward No. Date
NAME: Smith, Mary MEDICAL RECORD SSN: 555-55-5555 SERVICE TREATMENT PLAN
Automated VA Form 10-0043a