GAUTAM SEHGAL, M.D.
Medical Director 228 South Orange Avenue
Gautam Sehgal, M.D. South Orange, NJ 07079
Specialized in Neurology, Physiatry Phone: (973) 253-0505
Member of American Academy of Neurology Fax:(973) 253-2255
Hospital Privileges: E.O. General (E Orange), St. Michael
(Newark), St. James (Newark), Columbus Hospital (Newark)
Patient: Francois Compere
Referred by: Dr. Baptiste
AGE: 43-year-old. Sex: Male
Dear Dr. Baptiste:
Thank you for letting me to participate in the evaluation, management and treatment of your patient, Francois Compere. As you are aware, he is a 43-year-old male, who was ...view middle of the document...
There is no urinary or bowel incontinence. Minimal aggravation with cough and sneezing activities. Neck and back pains do interfere with daily, social, work and recreational activities.
PAST MEDICAL HISTORY:
No diabetes. No hypertension. No heart disease. No kidney disease.
No previous accidents. No subsequent accidents. He was totally asymptomatic prior to the accident.
The patient is single. The patient does not smoke or drink.
The patient is currently employed. He missed about three days from work.
Patient: Francois Compere
EFFECT ON LIFESTYLE:
Limited in daily activities as a result of the accident. He is unable to sit or stand for prolonged periods of time.
REVIEW OF SYSTEMS:
The MRI of the cervical spine shows a disc herniation at C4-C5 and bulge at C6-C7. The MRI of the lumbosacral spine shows L4-L5 L5-S1 bulge.
General: He is awake, alert, in moderate distress because of pain.
HEENT: Head is normocephalic, atraumatic, no Battle sign, no cranial bruits.
Neck: Supple. Carotids 2+. No bruit.
Lungs: Clear to auscultation and percussion. No rales or rhonchi.
Heart: Normal sinus rhythm. No murmur or gallops.
Abdomen: Soft and nontender. Bowel sounds are present. No organomegaly.
Extremities: No clubbing. No cyanosis. No edema. Peripheral pulses are felt.
CERVICAL SPINE: Diffuse cervical spasm with moderate degree of tenderness over cervical spine. Bilateral trapezius tenderness is present, left more than the right side. Foraminal compression test is positive. Shoulder Depression test is positive. Head distraction is positive. Negative Tinel’s sign and negative Phalen’s sign.
LUMBOSACRAL SPINE: Diffuse paralumbar spasm, L1-SI. Straight-leg raising is positive, right 70 degrees, left 60 degree. No CVA tenderness. No scoliosis. Limited and painful range of motion in flexion, extension and lateral rotation. Sciatic notch tenderness is present on the left.
Mental Status: The patient is awake, alert, and oriented x3. Memory, affect and judgment intact.
Speech: Fluent. No evidence of anomia, aphasia or any paraphasic errors.
Cranial Nerve Examination: Extraocular movements are full. No nystagmus. Fundus benign. Tongue midline. Hearing is intact. Bulbar exam is intact.
Motor System Examination: There is no drift. Power is 5/5 throughout. There is no atrophy. No fasciculations. No abnormal movements.
Deep tendon reflexes: Are 2+...