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)

NEUROLOGICAL CONSULTATION

Patient: Francois Compere
Referred by: Dr. Baptiste
D.O.S.: 04/21/2011
D.O.A.: 11/09/2010
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 involved in an automobile accident. According to the patient, he was the driver of the vehicle with his seatbelt on. The car was struck on the back right side. There is history of head trauma and no loss of consciousness. The patient was shaken up and dazed. The patient was taken to UMDNJ, treated, examined and released. For detail, please refer to the police report. Since the accident, the patient has been under your care, but remains symptomatic in spite of conservative therapy for close to six months, and is referred to me for further evaluation.

PRESENT COMPLAINTS:
On the day of examination, i.e. today, 04/21/2011, he complains of neck pain with stiffness. Neck pain is dull-to-sharp radiating into the both upper extremities, left more than right with the numbness, tingling and weakness all the way down to the fingers especially second and third fingers of the left hand. Neck pain is 9/10. Neck pain gets worse with prolong sitting and twisting activities. No aggravation with cough and sneezing activities. There is no urinary or bowel incontinence. He also complains of back pain with stiffness which is dull-to-sharp, going down to the both lower extremities. Back pain is 9/10. 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.

PREVIOUS ACCIDENT:
No previous accidents. No subsequent accidents. He was totally asymptomatic prior to the accident.

SOCIAL HISTORY:
The patient is single. The patient does not smoke or drink.

EMPLOYMENT HISTORY:
The patient is currently employed. He missed about three days from work.

Patient: Francois Compere
D.O.S.: 04/21/2011
Page: 2

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:
Unremarkable.

RECORD REVIEW:
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.

PHYSICAL EXAMINATION:
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.

NEUROLOGICAL EXAMINATION:
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+ bilaterally symmetrical, except for slight asymmetry of the left triceps 1+ and left ankle 1+ as compared to 2+ on the right side. No clonus, ankle or patellar.
Cerebellar: Intact.
Gait: Unremarkable. Some difficulty with heel-to-toe gait on the left side.
Sensory Examination: Grossly intact to light touch and pinprick. Although, the patient has subjective paresthesias.

Patient: Francois Compere
D.O.S.: 04/21/2011
Page: 3

DIAGNOSTIC IMPRESSION: • Status post automobile accident with post-traumatic cervical sprain/strain rule out radiculitis versus neuropathy versus plexopathy because of persistent radiating pain in the upper extremities with the numbness and tingling in spite of conservative therapy and positive MRI. (847.0/723.4). • Post-traumatic lumbosacral sprain/strain with the possibility of radiculitis versus neuropathy versus plexopathy because of radiating pain, which is persistent in spite of conservative therapy, positive MRI, positive ortho/neuro sign and positive reflex changes. (846.0/724.4). • Blunt head trauma.

PLAN: 1. The patient was advised to continue chiropractic care. 2. The patient was advised to avoid any activities, which might aggravate the condition or delay the healing. 3. The patient was advised to get the NCVs of the both upper and the both lower extremities and EMG of the left upper and the both lower extremities to document any evidence of cervical or lumbosacral radiculopathy versus neuropathy versus plexopathy, as this cannot be done based upon electrodiagnostic studies, neither can be done by MRI alone, since the MRI is an anatomical test.

HOW TESTING WILL AFFECT TEATMENT PLAN:
Once a diagnosis has been established by the electrodiagnostic studies, it will help us change the treatment plan in the form of: 1. Pain management evaluation. 2. Epidural injections. 3. Manipulation under anesthesia. 4. Neurosurgical intervention.

All treatment options have been discussed in detail with the patient. The patient agrees with the plan.

PROGNOSIS:
Based upon the patient’s history, physical findings, persistence of symptoms after the accident, absence of symptoms prior to the accident, positive MRI, positive ortho/neuro signs, positive reflex changes, limited daily activities, limited range of motion, and no subsequent accidents, it is my opinion based upon the reasonable degree of probability, that the patient’s injuries are related to the accident of 11/09/2010.

Thank you once again. If you have any further questions, please feel free to contact me.

__________________
Gautam Sehgal, M.D.
Neurologist