On examination, the patient is a pleasant female who appeared in some discomfort, not in acute distress. Cranial nerve examination II through XII are grossly intact. Motor strength is 5/5 in bilateral upper extremities. Motor strength is 5/5 in bilateral lower extremities. The left anterior tibialis is -5/5. Deep tendon reflexes are 2+ throughout except for left Achilles tendon which is 1+. Babinski is downgoing. Hoffman is negative. C-spine, the patient has minimal tenderness on the paraspinal area. Range of motion of C-spine is severely restricted and painful. Positive Spurling sign bilaterally. LS-spine, the patient has moderate tenderness on the lower lumbar paraspinal area and palpable spasm. Full flexion and extension with moderate restricted with moderate to severe pain at end points. No tenderness in the SI joint. Positive straight leg raise on the left is at 40 and on the right is 70.
Myofascial pain syndrome.
Lumbar spine stenosis.
I will schedule the patient for EMG of bilateral lower extremities to differentiate between neuropathy, plexopathy, as well as lumbar radiculopathy. Depending on the results of EMG, we will decide the further course of treatment. I will also prescribe the patient Ultracet one tablet two to three times a day p.r.n. for pain. The patient is to follow up with Dr. as advised.