DATE OF PROCEDURE: MM/DD/YYYY
PROCEDURE PERFORMED: EMG/nerve conduction study.
REFERRING PHYSICIAN: John Doe, MD
INDICATION FOR PROCEDURE: The patient is a (XX)-year-old male who complains of constant burning pain in his neck, in his shoulder, primarily in the right. He also describes some numbness and tingling in his left hand, primarily in the third through fifth digits. Those are the most affected but to a lesser extent in his first and second digits, and on his right hand, he is also noting some dysesthesias in his fifth digit. The patient has undergone cervical surgery in the past. He has undergone fusion at multiple levels.
SUMMARY:
1. Nerve conduction studies were performed on the bilateral upper extremities.
2. Bilateral median and bilateral ulnar sensory nerve action potentials were within normal limits for latency and amplitude.
3. Bilateral median motor and bilateral ulnar motor complex muscle action potentials were within normal limits for latency, amplitude and conduction velocities.
4. Needle examination was performed on the bilateral upper extremities and associated paraspinal muscles. There was increased muscle membrane irritability noted but isolated to the left and first dorsal interosseous muscle and had associated occasional positive waves. There were also complex repetitive discharges noted on the left pronator teres muscle and with all the spontaneous activity noted in the needle portion of the examination. There was no increased muscle membrane irritability or abnormal activity in the paraspinals bilaterally. Concerning volitional motor unit activity, there was significant abnormality throughout the left side, and to a lesser extent, there were some abnormalities noted also on the right side. On the left side, there was evidence of increased amplitudes, primarily in the pronator teres and triceps, primarily C6 and C7 region and also in the FDI. There were slight increased amplitudes noted on the right side and in the biceps, triceps, abductor pollicis brevis and also in the FDI. Additionally, there was decreased interference pattern noted in the pronator teres on the left and also on the triceps on the left, to a lesser extent in the FDI on the left.
IMPRESSION:
1. Abnormal study.
2. There is electrodiagnostic evidence of a chronic cervical radiculopathy, more prominent on the left side than on the right side. The left-sided findings are suggestive of a possible more acute/subacute process given the increased muscle membrane irritability noted in the FDI on the left side. There is absence of any abnormal spontaneous activity noted in the paraspinal muscles. It may make it more of a chronic active radiculopathy with left-sided findings greater than right-sided findings, and there are multiple levels involved. There is no electrodiagnostic evidence of a peripheral neuropathy on today’s examination. A new sterile disposable needle was used and discarded.
Thank you very much for this referral.
PROCEDURE PERFORMED: EMG/nerve conduction study.
INDICATION FOR PROCEDURE: The patient is a (XX)-year-old female who complains of numbness and tingling in her left great toe for approximately the last three months. The patient has had some change in her weight. No shoe wear change is noted. She denies any history of back pain, injury, surgery or symptoms. She denies any diabetes, thyroid disease, cancer, or excess alcohol consumption.
SUMMARY:
1. Nerve conduction studies were performed on the left lower extremity.
2. Left sural sensory nerve action potential was slightly prolonged and slightly diminished at 5.2 msec and 4.7 microvolts with a reference range for normal being less than or equal to 4.2 msec and greater than or equal to 5 microvolts. Left peroneal motor complex muscle action potential was within normal limits for latency, amplitude and conduction velocity. Left tibial motor complex muscle action potential was within normal limits for latency, amplitude and conduction velocity. Left peroneal F wave was within normal limits. Needle examination of the left lower extremity and associated paraspinal muscles showed no increased muscle membrane irritability, abnormal spontaneous activity or abnormal volitional motor units. Concerning her tibial response, there was slight slowing across the ankle portion, which could be consistent with a mild tarsal tunnel process going on, which could in some ways explain her current symptoms.
IMPRESSION: She does have sural sensory slowing, which may be an unrelated finding to her current symptoms or may be part of a more diffuse process. Overall, findings are really very benign on today’s testing, however, are only suggestive of possible early mild findings of the tarsal tunnel. A new sterile disposable needle was used and discarded.
Thank you very much for this referral.
