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PATTERN SHIFT VISUAL EVOKED POTENTIAL STUDY
Visual acuity left eye 20/200, right eye 20/25 with glasses. After full field stimulation of each eye, waves N1, P1, and N2 are identified. The P1 absolute latencies are left eye 95.5, right eye 98.0. The P1 difference is 2.5 msec. The amplitude ratio is 86.2%.

SUMMARY Decreased visual acuity, left eye. Pattern shift visual evoked potential study within normal limits.


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BRAIN STEM AUDITORY EVOKED POTENTIAL STUDY
Auditory Threshold: Left ear 20 db, right ear 20 db. After stimulating each ear, waves 1, 3, and 5 are identified. The absolute latencies, interwave latencies, and interear, interwave differences are normal. The amplitudes of waves 1 and 5 are normal. The 1/5 amplitude ratios are normal.

SUMMARY
Normal brain stem auditory evoked potential study.


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ELECTRONYSTAGMOGRAPHY REPORT (ENG)
CLINICAL HISTORY
This is a 43 year old with seizure disorder and recent imbalance with stair climbing. The following examinations are performed with horizontal and vertical electrodes.

Saccadic eye movements are well organized in the horizontal and in the vertical directions. Gaze and fixation testing, including straight gaze, gaze to the left, gaze to the right, and gaze upward and downward, produces no nystagmus. The oscillating tracking test reveals well-organized horizontal pursuit movements to each side.

Bidirectional opticokinetic testing with peripheral stimulation produces horizontal nystagmus of appropriate direction with the targets moving to each side. The torsion swing test with the eyes closed produces normal direction-changing horizontal nystagmus. Positional head testing with the eyes closed and the patient in the head hanging, left lateral, right lateral, and sitting positions produces no nystagmus. Cold and warm water caloric testing of each ear produces horizontal nystagmus of appropriate direction.

SUMMARY
Electronystagmography within normal limits.


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ELECTROENCEPHALOGRAM REPORT (EEG)
Age: 62. Patient is on Neurontin, phenobarbital, and Dilantin.

ANALYSIS OF PATTERN
There is a bioccipital rhythm, which is organized, of about 8 Hz. Frontal activity is a mixture of rapid and slow activity. Bifrontal spike and slow wave activities are noted, which have been noted in previous EEGs. High voltage delta slow waves are also noted intermittently in the frontal areas. The spike activity noted does not generalize but spreads occipitally. Interictally, the EEG has some slow theta activity in the 5-6 Hz range. The spike and slow activity is not frequent but intermittently increases in frequency. Tow episodes of every 1 second, lasting 4 seconds, are recorded. Otherwise, the spike activity appears between 2 minutes to 3 minutes in the EEG. The high-frequency delta waves are not as frequent. One episode lasting up to 5 seconds is also noted. No clinical correlation was noted with this EEG by the EEG tech or by the patient. The patient is not photosensitive.

IMPRESSION
Compared to the previous EEG, it is either unchanged or slightly better.


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ELECTROMYOGRAPHY (EMG)
NEUROLOGICAL AND ELECTRODIAGNOSTIC CONSULTATION
This is a 44-year-old white female with left lower extremity pain. Approximately one month ago, the patient, while descending stairs, was almost tripped by her cat. The patient put her left leg out in front of her to prevent a fall. She felt "a shock" in the center of the left knee. She subsequently had numbness of the entire left knee. Subsequently, the left knee pain radiated into the quadriceps muscle and into the lower leg and ankle. "The whole leg felt terrible." Because of pains in the knee, the leg would jump at night. She had X-rays of the knee, which she understands were "fine." The knee was immobilized by a splint. She had a orthopedic evaluation. She subsequently had physical therapy. The patient noticed increased left knee pain after the use of a Hydrocollator pack. She continues to complain of left knee pain. Now she cannot sit for longer than 1-1/2 hours because she develop a burning sensation in the left knee. The burning radiates to the posterior lower leg and subsequently also radiates into the posterior thigh. If she stands for a prolonged period of time, she has pins and needles sensations in the anterior left knee. With prolonged standing, the left knee seems to give out from underneath her. When she keeps her left leg dependent, the left knee tends to burn, and she has burning sensations at the back of the left lower leg and in the heel. The patient also complains of some back discomfort in the middle of the low back for approximately one month. She describes this sensation, "It feels like muscles." There are no right leg symptoms and no bladder or bowel symptoms.

The patient is using Advil, 3 tablets q.4-5h. She also tried Valium q.h.s., which is helpful.

PAST HISTORY: The patient has had a tonsillectomy and a tubal ligation. She has hayfever but no medication allergies. There have been no other significant prior illnesses.

SOCIAL HISTORY: Prior to the left leg problem, the patient was doing temporary office work. She now, however, is unable to work.

NEUROLOGICAL EXAMINATION: The neurological examination reveals the patient to be a well-developed, well-nourished white female. A single 1 x 2-inch cafe-au-lait spot is present over the dorsum of the left foot just proximal to the 4th and 5th toes. Bending forward with the knees extended, the patient misses her toes with her fingertips by 6 inches. Straight leg raising of the right leg is negative at 75 degrees; straight leg raising of the left leg at 75 degrees produces some discomfort only in the area of the left hip. Bent leg raising is negative. The patient complains of severe pain on compression of any part or side of the left knee.

All major muscle groups have strong symmetrical power. The patient complains of a great deal of left knee pain when she attempts to contract the extensors of the left knee strongly. There appears to be dullness to pin over the dorsum of the left large toe and over the lateral aspect of the left foot. Pin sensation is, otherwise, intact, including all of the other lumbar dermatomes. Position and vibratory sensations are normal. The deep tendon reflexes are 2+ and symmetrical. Both toes are down-going. The Romberg test is negative. There is no drift of the outstretched extremities. The pupils and fundi are normal.


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ELECTROMYOGRAPHIC STUDY
The following muscles are examined in the lower extremities: extensor digitorum brevis, anterior tibial and peronei, quadriceps, gastrocnemius muscles, biceps femoris, and semitendinous muscles. The lumbosacral paraspinal muscles could not be examined because of poor needle electrode tolerance. In all of the muscles studied, the insertional activity was normal. There was no abnormal activity at rest. The motor units were of normal size and duration. The recruitment pattern was full.
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NERVE CONDUCTION VELOCITY STUDY
(The patient's height is 5'2")
Left peroneal nerve: Terminal latency 3.20; NCV 45.5 mps.
Right peroneal nerve: Terminal latency 3.24; NCV 47.8 mps.
Left tibial nerve: Terminal latency 4.90; NCV 48.1 mps.
Right tibial nerve: Terminal latency 4.16; NCV 47.1 mps.

SENSORY RESULTS
Left superficial peroneal nerve: Terminal latency 3.16; NCV 47.5 mps.
Right superficial peroneal nerve: Terminal latency 3.08; NCV 47.2 mps.
Left sural nerve: Terminal latency 2.96; NCV 50.7 mps.
Right sural nerve: Terminal latency 2.94; NCV 51.0 mps.

LATE RESPONSES
F-wave latencies
Left peroneal nerve 46.0
Right peroneal nerve 45.8
Left tibial nerve 46.0
Right tibial nerve 46.4

H-reflex latencies
Left sciatic nerve 27.7
Right sciatic nerve 28.4

The amplitudes of the motor action potentials produced by stimulating the left and right peroneal nerves are low. The amplitudes of the other motor action potentials are normal.

SUMMARY
The most striking feature of the patient's neurological examination is the great deal of pain produced by compression or palpation of any part of the left knee. She appears to have dullness to pin over the left large toe and over the lateral aspect of the left foot.

The electromyographic study was limited by poor needle electrode tolerance. The muscles which were able to be examined, however, were normal.

The nerve conduction velocity study was mildly abnormal because of the low amplitude of the motor action potentials produced by stimulating the left and the right peroneal nerves. This was a very symmetrical finding. The rest of the nerve conduction velocity study is normal.

The etiology of the patient's left lower extremity symptoms remains unclear. Although the pin sensation findings suggest the possibility of a lumbar root problem, the finding is subjective in nature, and there are no other definite signs of nerve root injury. The pain on compression of the left knee suggests a primary knee problem.

I have administered Anaprox, 275 mg q.i.d. with food or milk. A bone scan is additionally requested. Also requested are a CBC, arthritis profile, and special chemistry profile.

Thank you very much for asking me to examine this patient.


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