Muscle weakness

The patient comes today for an initial consultation. He presents complaining of poor motor coordination and balance problems. He had cervical fusion a year and half ago. He had anterior cervical interbody fusion for cervical spinal stenosis. Prior to the surgery, he could not even walk because of inability to coordinate muscle movements of his extremities. It involves all four extremities mainly the lower extremities. Since surgery, this has improved somewhat, but he still has significant problems. With ambulation, he drags his feet and has developed a varus type of gait. He often times has to lean up against the wall to keep from falling. He does not have issues with falling but has problem with tripping and having to catch himself from following. He had physical therapy after surgery for strengthening without any improvement. He also complains of increased levels of forgetfulness. The symptoms began in 2010 and stayed about the same overall. He denies any pain, numbness or tingling in the extremities.

DIAGNOSES:
Gait abnormality.
Cervical stenosis.
Poor motor coordination.
Muscle weakness.

RECOMMENDATIONS:
Dr. came and spoke with the patient and examined the patient. We recommend that the patient undergo balance plate testing and possible VNG testing. We will recommend MRI of the brain without contrast to rule out any demyelinating or central processes that may be causing the symptoms. We would like to review and get records from Dr. his orthopedic surgeon. We will also recommend the patient see a neurologist for an evaluation. We will see the patient back in two-week period of time for the balance testing and review results of his MRI of the brain.

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