This is an 82-year-old female patient, who presents to the pain management center today with complaint of numbness and tingling in the lower extremities. She has numbness and tingling from the knees down to her feet and trouble walking. She has been told by her family member that she does not extend and flex her ankle when she walks and has an abnormal gait associated with this. The patient intermittently feels imbalanced and dizzy. She also has some pain in the lower lumbar spine as well. At times, the pain is shooting down the legs with prolonged walking. She rates the pain level in the low back as a 3/10 on visual analog scale. It is an aching type of pain. She is having symptoms over a number of years and progressively worsened. It has been mostly on and off. She had a motor vehicle accident a number of years ago and fell down some stairs six years ago. Symptoms are aggravated with walking for any extended period and decreased with rest. She has had chiropractic with temporary relief in the past. She has had some injections in her feet from plantar fasciitis by a podiatrist. Symptoms have progressively gotten worse.
Time-out was taken to explain clinical findings, assessment, diagnosis, and treatment recommendations. Dr. came and saw the patient, examined the patient, and recommended following plan of care. We will get MRI of the lumbar spine without contrast to rule out stenosis. We also recommended a lower extremity EMG study to rule out a neuropathic source versus radicular source of her symptoms in her lower extremities. We recommended she follow up with her endocrinologist regarding her thyroid. Consider lumbar orthosis and consider balance testing at follow-up. We will see the patient next for her EMG studies. If she has any problems in the interim, she will contact the office.