Spinal stenosis

The patient comes in today for an initial consultation with complaints of neuropathy. He complains of tingling and pins and needle sensation from his knees down to his toes and his hands bilaterally. The symptoms were symmetrical in the upper and lower extremities. He has had symptoms on and off since 1996, progressively gotten worse. He is insulin-dependent diabetic. He has poor balance associated with this. He also has history of lower back pain with L4-L5 discectomy in 1996. He has been diagnosed with spinal stenosis. He has had recent epidural injections and radiofrequency neurolysis with facet joints with release of his lower back pain. He states he has no strength in his life with ambulation. He has had vascular studies within the last year, which came back normal per the patient. He is having no alleviating or aggravating factors. Neurontin does seem to provide some temporary relief. He is currently taking 300 mg of Neurontin, four tablets at bedtime and two during the day. He denies any other trauma, injuries, or accidents.

DIAGNOSES:
Peripheral neuropathy likely, related to diabetes.
Spinal stenosis.

RECOMMENDATIONS:
Dr. came and spoke with the patient and I reviewed the medical records and examined the patient. The clinical findings, treatment recommendation, and prognosis were discussed with the patient. I need most recent MRI reports. We will schedule the patient for an EMG study of the upper and lower extremities. We will consider possible peripheral nerve blocks with high frequency nerve stimulation. We will recommend diet control with diabetes. We need reports of recent vacular studies to rule out vacular source of his symptoms versus neuropathic symptoms. Recommended he continue with Neurontin and we will see him back in one-to-two weeks for his EMG study.

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