47 year old male truck driver presenting with low back pain associated with left leg weakness and numbness.
He had been normal prior to acute onset of symptoms several days prior to presentation. His symptoms started while driving. He denied any specific injury or doing any heavy lifting. His symptoms rapidly worsened over the following hours to the point where he was having difficulty walking and felt like his “left leg fell asleep and never woke up.” He had no recent infectious symptoms.
He took an appointment for initial evaluation. Basic labs and a lumbosacral x-ray were obtained.
He was referred to the physiotherapy dept. several days later. At that time, his back pain was improving. However, he continued to have symptoms down his left leg. He was now ambulating with a cane and had fallen several times. Visible atrophy of his left thigh muscles were noticed.
He had no history of malignancy, diabetes, or thyroid disease. He denied fevers, chills, saddle anesthesia, bowel/bladder issues, or IV drug use.
Back: No spinal or Paraspinal tenderness to palpation. Full range of motion in flexion, extension, rotation, and lateral bend. Positive straight leg raise and slump test on the left.
Left lower extremity:
Inspection: Visible atrophy of the quadriceps muscles.
Muscle strength: 4/5 hip flexors, 5/5 hip abduction and adduction, 2/5 knee extension, 5/5 knee flexion, 5/5 ankle dorsiflexion and plantarflexion.
Reflexes: Absent patellar and Achilles. No clonus.
Sensation: Decreased sensation in the anterior and medial thigh down to mid-calf with allodynia (pain resulting from light touch of the skin).
MRI lumbar spine: Mild degenerative changes including mild L3-L4 disc bulge. No spinal canal stenosis or nerve root compression. Case Photo #3
MRI lumbosacral plexus: Peripheral degeneration of L3-L4 nerve roots extending into the femoral nerve.
EMG/NCS: Abnormalities in distribution of femoral nerve proximal to the branch to the iliopsoas
Hematology: CBC within normal limits
Infectious: HIV, Syphilis, Hepatitis B and C, B. burgdorferi, cryptococcus, and tuberculosis all negative.
Autoimmune: ANA , dsDNA, ANCA, C3, C4, RF, RNP, Smith, SSA, and SSB all negative.
CSF: Cell counts, protein, glucose within normal limits. Normal MS profile.
Please provide a detailed SOAP note for clinical analysis of the subjective and objective findings of the case, Provide a possible estimated diagnosis then provide your physiotherapy goals and treatment paln accordingly
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