He was treated with 8 sessions of physical therapy. He consulted with Dr. Hambly on 6/5/16. He is here for another opinion on his situation. Dr. Hambly did not feel he was an optimal surgical candidate at that time. The patient is frustrated with his symptoms and feels he is very limited due to his pain. Previous treatment includes 8 sessions of physical therapy in December 2015, aspirin, and Motrin. Current medications include ibuprofen 200 mg, simvastatin 20 mg, Lisinopril 5 mg, Januvia 100 mg, aspirin 81 mg, metformin 500 mg, and glimperide 2 mg. Review of systems revealed night sweats, blurry vision, joint pain, muscle pain, muscle weakness, depression and anxiety. Physical examination revealed blood pressure of 135/84. Musculoskeletal/neurological examination revealed patellar reflexes are 2+. His strength is 5/5 in the lower extremities except extensor hallucis longus (EHL). He has decreased sensation in the L5 dermatome. Low back examination revealed that he has tenderness to palpation over the thoracolumbar paraspinals bilaterally. Straight leg raising is positive bilaterally eliciting pain in the L5 dermatome. He has lumbar flexion to 45 degrees with
He was treated with 8 sessions of physical therapy. He consulted with Dr. Hambly on 6/5/16. He is here for another opinion on his situation. Dr. Hambly did not feel he was an optimal surgical candidate at that time. The patient is frustrated with his symptoms and feels he is very limited due to his pain. Previous treatment includes 8 sessions of physical therapy in December 2015, aspirin, and Motrin. Current medications include ibuprofen 200 mg, simvastatin 20 mg, Lisinopril 5 mg, Januvia 100 mg, aspirin 81 mg, metformin 500 mg, and glimperide 2 mg. Review of systems revealed night sweats, blurry vision, joint pain, muscle pain, muscle weakness, depression and anxiety. Physical examination revealed blood pressure of 135/84. Musculoskeletal/neurological examination revealed patellar reflexes are 2+. His strength is 5/5 in the lower extremities except extensor hallucis longus (EHL). He has decreased sensation in the L5 dermatome. Low back examination revealed that he has tenderness to palpation over the thoracolumbar paraspinals bilaterally. Straight leg raising is positive bilaterally eliciting pain in the L5 dermatome. He has lumbar flexion to 45 degrees with