VIEWS: 48 PAGES: 4 POSTED ON: 1/7/2012
Page 1 Re: D/A: ROBERT KRONENBERG, M.D. QUEENS COMMUNITY MEDICAL CENTER 220-21 LINDEN BLVD. CAMBRIA HEIGHTS, NY 11411 718-276-4000 NEUROLOGY INITIAL EVALUATION Date: ......………, 2000 RE: /00 Auto Accident This is a ____ year old woman who states that on _______, 2000, as a pedestrian/ driver/ front/ left/ right rear seat passenger in/ of a car, she was involved in a motor vehicle accident. The patient reported sustaining injuries to the cervical, thoracic and lumbar spine, chest, abdomen and the right and left shoulders/ arms/ elbows/ wrists/ hands/ fingers and the right and left thighs/ hips/ knees/ ankles/ feet/ foot injuries. There was a/ no direct head trauma with possible/ without loss of consciousness during the accident. Following the accident the patient was clinically evaluated in Bellevue, Jamaica, Mary Immaculate, Woodhull, Medical Center/ Hospital emergency room where she was released the same day after her XRays were negative for fracture and she was given a prescription for OTC pain killers/ NSAIDs/ muscle relaxants. She is currently/to be followed by an internist, and receives physical therapy and chiropractic treatment. CHIEF COMPLAINTS: During this visit to my office, the patient presented with complaints of intermittent/ persistent/ constant/ right/ left/ temporal/ bitemporal/ occipital/ vertex/ diffuse/ and frontal/ throbbing/ sharp headaches, dizziness and vertigo, tinnitus on the left and right side, blurry vision, double vision, nausea and vomiting, morning stiffness in the neck, and pain in the neck radiating to the right and left shoulders/ arms/ forearms/ hands/ and the lower back. The patient also reported: numbness/ tingling/ paresthesias/ weakness/ and pain in her right and left shoulders/ and the right/ left arms/ forearms/ elbows/ hands and fingers. In addition, the patient also complained of constant/ intermittent persisting lower back pain which radiates to the right and left buttocks/ hips/ thighs/ knees/ legs/ foot/ feet/ and big toe/toes, as well as tingling/ paresthesias/ numbness/ weakness and pain in her right and left hips/ knees/ legs/ feet/ foot/ and big toe/ toes. The patient further reported anxiety, nervousness, fears, nightmares, depression, and poor sleep. She is in mild to moderate distress because of these symptoms MRI of the cervical spine was performed on /00 showing: straightening/ reversal of the cervical curvature/ lordosis, and a central posterior bulging discs at C -C ,C3-C4, C4-C5, C5-C6 and C6-C7 a herniating discs at C -C , C4-C5, C5-C6 and C6-C7 deforming the thecal sac and abutting the spinal cord centrally. MRI of the lumbosacral spine on /00 showed a posterior bulging/ herniating disc L3-L4 / L4-L5 / L5-S1. MRI of the brain on /00 revealed no demonstrable pathology. Page 2 Re: D/A: MRI of the right and left shoulders/ knees on /00revealed PAST MEDICAL HISTORY: There is no significant past medical history. There is a history of Hypertension , Diabetes Mellitus , Osteoarthritis , Bronchial Asthma , a prior trauma/ MVA with full recovery in FAMILY HISTORY: Unremarkable. There is a history of cancer, heart disease, hypertension and diabetes in the family. CURRENT MEDICATIONS: None. Tylenol #3/ Motrin/ Ibuprofen/ Naprosyn/ Aspirin PRN for pain. ALLERGIES: No known drug allergies. Penicillin, Sulfa- HABITS: Alcohol: No/ Socially/ Occasionally. Drugs: No. Smoking: No 0.5/ 1 /1.5 PPD for years. PHYSICAL AND NEUROLOGICAL EXAM: Physical examination: General appearance: This patient is a well-developed well-nourished ___ year old woman. Vital signs: Blood pressure is ____/___, pulse ___ and regular. Head, ears, eyes, nose throat: Head is atraumatic and normocephalic. Pupils were equal and reactive to light and accommodation and extra-ocular muscles were intact. The ears, nose, mouth and throat were unremarkable. Chest: The chest was symmetrical and the lungs were clear to percussion and auscultation. The heart was in regular rhythm and rate. Abdomen: The abdomen was soft, non-tender and non-distended with bowel sounds present. Extremities: Anterior Tibial, Dorsalis Pedis and Radial pulses were palpable and within normal limits. No leg edema was noted. Cervical spine: Moderate suboccipital tenderness in multiple areas along the Cervical spine, especially between the C - C levels, more on the right/ left side, with paraspinal muscles spasms noted and restriction of the range of motion to the right, left, and on flexion and extension. Foraminal test was positive. Lumbosacral spine: Moderate paraspinal tenderness in multiple areas along the Lumbar spine especially between the L- S1 levels, more on the right/ left side, with paraspinal muscles spasms noted and restriction of the range of motion to the right, left, and on flexion and extension. Neurologic examination: Mental status: The patient is awake, alert and oriented to person, place and time, and cooperative. Speech is fluent, memory intact, attention span is normal. The patient’s affect appeared appropriate. Cranial nerves II-XII: Visual fields full, fundi benign, pupils equally round without nystagmus. Facial sensation is intact bilaterally, corneal reflexes are normal, face is symmetrical to midline. Page 3 Re: D/A: The remainder of the cranial nerves are normal. Motor system: The upper and lower extremities had no atrophy and normal muscle tone with full power in all muscle. Deep tendon reflexes were active and symmetric. The plantar response was flexor. Sensory exam: Decreased response to light touch and pinprick in the distribution of the right and left C- nerve root, and decreased response to light touch and pinprick in the distribution of the right and left L-4, L-5 and S-1 nerve roots. Cerebellar system: Finger to nose and heel to shin tests, and rapidly alternating movements were within normal limits. Romberg’s test was negative. Gait: Demonstrated no ataxia. IMPRESSION: This is a ___ year old woman status post a recent motor vehicle accident. Her neurologic examination is remarkable for moderate mechanical deficits of the cervical and lumbar spine and sensory deficit in the distributions of the right and left C- and the right and left L- and S-1 nerve roots. DIAGNOSIS: 1. Cervical and Lumbar muscles Posttraumatic Sprain syndrome. 2. R/O Posttraumatic cervical radiculopathy due to mechanical injury of the C- nerve root on the right and left side. 3. R/O Posttraumatic lumbar radiculopathy due to mechanical injury of the L- and S-1 nerve roots on the right and left side. Posttraumatic lumbar pain syndrome. 4. Post Concussion Syndrome 5. Posttraumatic Vertigo. 6. Cephalgia, vertebrogenic and posttraumatic 7. Anterior chest wall contusion. 8. Thoracic Myofascitis. 9. Right/ Left/ Both shoulders/ arms/ elbows/ forearms/ wrists/ hands contusions/ abrasions/ severe sprains. R/O ligaments tears and synovial injuries 10. Right/ Left/ Both hips/ thighs/ knees/ legs/ ankles/ foot/ feet contusions/ abrasions/ severe sprains. R/O ligaments tears and synovial injuries 11. Posttraumatic Stress disorder/ R/O Anxiety disorder/ R/O Depression. RECOMMENDATIONS: 1. Start/ Continue physical therapy, acupuncture and chiropractic treatments. 2. Start/ Continue physical therapy, acupuncture and chiropractic treatments. 3. Tylenol 650 mg / #3/ #4 Q4 hr. PRN for headache and pain. 4. Consider NSAIDs with persisting symptoms. Continue/ Increase Start Ibuprofen/ Ketoprofen/ Naprosyn/ Relafen 100/ 220/ 375/ 400/ 440/ 500/ 600/ 750/ 800 mg PO QD/ BID/ TID / QID/ Q 4 / 6/ 8 Hours/ PRN for headache and pain, with antacids PRN. 4. To clarify the possibility of cervical and lumbar nerve root compression, I would like to perform neurophysiologic testing as EMG/NCV studies of the upper and lower extremities. 6. Consider NCV/EMG studies with persisting symptoms. 7. SSEP studies if necessary to diagnose radiculopathy. 8. BAER to rule out brainstem involvement as an etiology of vertigo. 9. MRI of the brain to exclude intracranial pathology. Page 4 Re: D/A: 10. MRI of the Cervical and Thoracic/ Lumbar spine to rule out discogenic injury. 11. MRI of the right and left shoulder/ wrist/ hip/ knee/ ankle to rule out ligaments tears and synovial injuries. 12. Psychiatrist evaluation and follow-up to control the patient’s symptoms. 13. Internist evaluation/ follow-up to assess for/ treat for hypertension. 14 Orthopedist consultation to assess muscular-skeletal problems. 15. Cervical collar, cervical pillow, cervical traction, LSO (elastic), lumbar cushion, car seat, wrist/ knee/ ankle support, arm sling, Thermophore, body massager. 16. Neurological follow-up exam in 1-2/ 2-3/ 3-4 weeks. I believe that all of the above mentioned problems are causally related to the motor vehicle accident on______, 2000 and these neurological deficits can persist for an indefinite period of time affecting the patient’s mobility and consequently the quality of her life. Thank you for the courtesy of this referral. Very truly yours, Robert Kronenberg, M.D.
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