Pt is a 59 year old female with a history of sciatica, lumbar degenerative disc disease

and spinal stenos, who presents to me today with complains of left ankle pain. Pt
states one year ago she did sprain her ankle and was treated conservatively with
bracing. She does say that this worked at the time however the pain has come back.
She has tried ibuprofen for the pain with no relief. She states this pain feels like
burning and tingling. She also admits to experiencing numbness of the ankle in the
past with some radiation up the lateral aspect of the left leg. Pt states the pain has
subsided a bit, and has been more severe in the weeks leading up to this visit. Pt has
had lumbar spine injections in the past which have helped her pain.

Patient is alert and oriented x 3 and in no acute distress. Mood and affect are
normal. Trachea is midline and respirations are non-labored. Patient in no acute
distress. Normocephalic. EOMI. Anicteric sclerae. No neck vein distention. Abdomen
is soft and non-tender. Skin is warm dry and intact with no visible rashes or lesions
to the upper or lower extremities, neck or upper trunk area. Neurovascular exam is
normal through the extremities. No lymphadenopathy noted to the extremities.
There is no gross deformity or erythema to the left leg or ankle. Tenderness is noted
laterally at the ankle and the distal leg. No tenderness is noted medially at the ankle.
Full ROM at the lumbar spine and at the ankle. Pt is neurovascularly intact.
Weakness is noted on extension at the knee and significant EHL weakness is also
noted.

X-rays of the left ankle were ordered and reviewed with the indication of left ankle
pain. AP/Lateral/Mortise views are negative

ASSESSMENT/PLAN: Pt has been diagnosed with ankle pain likely due to lumbar
spinal stenosis and degenerative disc disease. This is confirmed by an MRI of the
lumbar spine done previously which we have reviewed. We will refer her to spinal
surgeon Dr. Kelley. We will follow-up with her as needed.