Download VA Palo Health Care System - Palo Alto Division

Department of Veterans Affairs
MEDICAL RECORD
SERVICE TREATMENT PLAN
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
Enter in space below - PATIENT IDENTIFICATION - Treating Facility - Ward No.
NAME: Smith, Mary
SSN: 555-55-5555
DATE
3/22/06
Date
MEDICAL RECORD
SERVICE TREATMENT
PLAN
Automated VA Form 10-0043a
MEDICAL RECORD
Department of Veterans Affairs
Manual muscle testing:
Hip
Knee
Knee
Dorsi Flex
Flexion
Flex
Ext
4*
4*
4*
4*
Right
4*
4*
4*
4*
Left
*: pain limited, EHL: extensor hallucis longus
SERVICE TREATMENT PLAN
EHL
4*
4*
Plantar
Flex
4*
4*
Muscle stretch reflexes
Left
Right
Patella
2
2
Medial Hamstring
0
0
Ankle Jerk
2
2
Circumferences
Thigh
58
56
Right (cm)
Left (cm)
Calf
41
41
RESULTS:
NERVE CONDUCTION STUDIES:
Motor Nerve Conduction:
Nerve and Site
Latency Amplitude
Peroneal.L
Ankle
Fibula (head)
Tibial.L
Ankle
Popliteal fossa
Segment
4.2 ms
8.1 mV
9.8 ms
8.2 mV
Extensor digitorum
brevis-Ankle
Ankle-Fibula (head)
4.7 ms
11.3 ms
16.7 mV
16.2 mV
Abductor hallucis-Ankle
Ankle-Popliteal fossa
Sensory Nerve Conduction:
Nerve and Site
Onset
Peak
Latency
Latency
Sural.L
Lower leg
3.3 ms
4.0 ms
Amplitude
11 uV
Segment
Ankle-Lower leg
Latency
Difference
Distance
Conduction
Velocity
4.2 ms
80 mm
m/s
5.6 ms
300 mm
54 m/s
4.7 ms
6.6 ms
80 mm
330 mm
m/s
50 m/s
Latency
Difference
Distance
Conduction
Velocity
3.3 ms
mm
m/s
Nerve conduction studies in the left lower extremity were normal.
SIGNATURE/TITLE OF PRACTITIONER
Enter in space below - PATIENT IDENTIFICATION - Treating Facility - Ward No.
NAME: Smith, Mary
SSN: 555-55-5555
DATE
3/22/06
Date
MEDICAL RECORD
SERVICE TREATMENT
PLAN
Automated VA Form 10-0043a
Department of Veterans Affairs
MEDICAL RECORD
SERVICE TREATMENT PLAN
Needle EMG Examination:
Insertional Spontaneous Activity
Muscle
Insertional
Fibs
+ Wave
Tibialis anterior.L
Normal
None
None
Gastrocnemius
Normal
None
None
(Medial head).L
Vastus medialis.L
Normal
None
None
Biceps femoris
Normal
None
None
(long head).L
Gluteus minimus.L Normal
None
None
L4 paraspinal.L
Normal
None
None
L5 paraspinal.L
Normal
None
None
Fasc
None
None
Other
Volitional MUAPs
Duration Amplitude
Normal
Normal
Normal
Normal
Poly
None
None
Recruitment
Normal
Normal
None
None
Normal
Normal
Normal
Normal
None
None
Normal
Normal
None
None
None
Normal
Normal
Normal
Normal
Normal
Normal
None
None
None
Normal
Normal
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.
Attending in PM&R
________________
Jane Johnson, MD
Resident in PM&R
SIGNATURE/TITLE OF PRACTITIONER
Enter in space below - PATIENT IDENTIFICATION - Treating Facility - Ward No.
NAME: Smith, Mary
SSN: 555-55-5555
DATE
3/22/06
Date
MEDICAL RECORD
SERVICE TREATMENT
PLAN
Automated VA Form 10-0043a