We had the pleasure of seeing your patient at the neuromuscular clinic at California Pacific Medical Center. I reviewed the medical records.
History of Present Illness:
As you know, [patient] is a 76 year old male who is referred for evaluation of Fatigue and myalgia.
Battery of blood tests for causation of symptoms all normal.
Comes today for EMG studies.
MEDICATIONS:
No outpatient prescriptions have been marked as taking for the 8/1/18 encounter (Office Visit) with [doctor].
PAST HISTORY:
PHYSICAL EXAMINATION:
Vitals: BP 124/69 | Pulse 76 | Wt 81.5 kg (179 lb 9.6 oz)
General: Well appearing male in no apparent distress.
Neurological Examination:
Mental Status:
The patient was alert and cooperative during the interview. Orientation was normal to time, place and person.
Cranial Nerves:
The pupils are equal, round and reactive to light and accommodation. Extraocular movements were full, without nystagmus. Tongue and uvula were midline with normal palate elevation. There was normal tongue, SCM and trapezius strength. Neck flexion and extension was 5/5.
Motor Exam:
Motor examination revealed normal bulk and tone throughout. Power examination showed full strength.
Sensory:
Sensory examination was normal for light touch, pin prick, vibratory senses and joint position sense.
Coordination:
Finger-to-nose testing and rapid alternating movements were normal.
Gait:
Tandem gait was normal. Heel walking and toe walking were normal. Romberg test was negative.
DTRs:
Normal
IMPRESSION:
[Patient] is a 76 year old male, who was seen today for evaluation of fatigue and myalgia. Examination shows no deficits. EMG/NCV (see report below) studies showed no significant abnormality. Findiungs are most suggestive of fibromyalgia and chronic fatigue.
PLAN and RECOMMENDATIONS:
(1) discussed diagnosis and reassured about normal work up
(2) We will see him in follow-up prn
We thank you for this referral.
Sincerely,
[Doctor]
A total of 40 minutes was spent with the patient of which 25 minutes was devoted to counseling about medications, diagnosis and prognosis.
ELECTRODIAGNOSTIC FINDINGS:
Right Median and Ulnar motor nerve conduction studies were normal.
Right Median and Ulnar sensory nerve conduction studies were normal; including the short segment across the carpal tunnel.
Right EMG studies were normal in cervical paraspinals, biceps, triceps, extensor digitorum communis, first dorsal interosseous and abductor pollicis brevis muscles. There was no abnormal spontaneous activity and motor unit potentials were normally configured and recruited in all muscles.
right Peroneal and Tibial motor nerve conduction studies were normal.
right Sural and superficial peroneal nerve conduction studies were normal.
Repetitive stimulation of TA and trapezius were normal.
right leg needle EMG studies in the vastus lateralis, vastus medialis, biceps femoris, tibialis anterior, medial gastrocnemius, and paraspinals were normal.
There was no abnormal spontaneous activity and motor unit potentials were normally configured and recruited in all muscles.
INTERPRETATION:
No electrodiagnostic abnormality was found on this examination. There was no evidence of radiculopathy, myasthenia, myopathy or neuropathy.
MD SIGNATURE:
[Doctor]