Download Alba Hernandez

Alba Hernandez
1/18/2000 – Restrained driver in a midsize car traveling at slow speed when impacted in
the front by a midsize car traveling at moderate speed. Patient’s body struck steering
wheel. No LOC per EMS. GCS was 15 at scene. She was transported to the Holmes
Regional Medical Center ED. In the ED she complained of chest, neck, back, and right
foot pain. ER eval on 1/18/00 included x-rays, which revealed mild anterior hypertrophic
osteophyte formation at C4-5, mild loss of disc space height at C4-5, likely to be
degenerative. Mild ostophyte formation in thoracic spine also indicated. She was
discharged on Naprosyn, Robaxin, and Lortab and instructed to follow up with her PCP
in 1 week.
Seen shortly thereafter (1/20/01; Netter) with tenderness in upper back, bruised right foot
(severe sprain) cervical and upper back spasm and strain, as well as multiple contusions
and abrasions.
MRI of cervical spine (Weiss) in 5/00 revealed disk herniation at C5-6 level. Thoracic
MRI is negative.
8/17/00 (Paine) – neurosurgical evaluation. Operation in 10/26/01 anterior cervical
diskectomy, anterior cervical disc fusion using cadaveric bone graft, structural allograft,
fragment fixation using 23mm Atlantis plate with 13mm screws” Dr. Paine saw Ms.
Hernandez again on 8/24/2007 for evaluation. She continued to have significant pain,
and had tried medications, traction, and the use of a TENS unit. MRI revealed disk
disease above and below the level of the prior surgery. Recommended conservative
treatment.
Has pre-existing pain complaints, including right carpal tunnel (6/98), pain in the left
mid-back, lack of energy (7/99), upper back spasm and strain (7/99), pain in upper back
and numbness in right hand (9/99)
MVA 1990’s in Bronx NY with no known sequelae
Elka Rivera, M.D. 3/22/04 – acute bronchitis; depressive disorder NEC. She was on
Zoloft but this was discontinued for unspecified reasons.
Dr. Ruiz: These records reflect primary care visits. 4/6/04; /27/2004– nasal congestion.
Diagnosis was otitis media.
David Spalding, M.D. 8/1/05; 8/31/05: office visits for shoulder/arm/knee/leg pain. She
was regarded as doing better. Stretching exercises were recommended.
Ruddy E. Ruiz, M.D.: Office visit 2/19/02. Initial visit. C/o episodes of chest pain,
palpitations, sometimes under period of stress. Mother is in the home and is developing
dementia. History of MVA with eventual surgery by Dr. Paine was described. Also
complaining of headaches after the accident. Medical evaluation was undertaken.
Office visit 5/29/03: Elevated blood pressure; stress at home with the illness of her son.
She is also taking Zoloft. Suggested routine exercise program, started on Diovan
80mg/daily. Office visit 7/10/03: no specific symptoms; blood pressure good.
Recommended preventative medicine (colonoscopy). Office visit 9/22/04: Symptoms of
dysphagia; was referred to ENT evaluation. Office visit 3/27/04: sore throat/cough.
Prescribed Z-Pak. Office visit 10/5/04: Office visit with complaints of esophageal
reflux. She was put on Nexium. Office visit 11/3/04: Office visit in which nonspecific
symptoms of dysphagia were described. She had been seen by ENT and had shown signs
of refulx. She had lost her son and was feeling depressed, and she was started on
Lexapro 10mg daily. Office visit 12/7/04: had stopped Lexapro due to side effect; was
actually better with the depression. Blood pressure was stable. Office visit 5/25/05:
Problems: GERD, chronic joint complaints for which a referral to Rheumatology was
arranged; hypertension.
GAP
Medical Records of Janet A. Anciro, M.D.(1/31/06 - )
These records describe internal medicine visits for a variety of complaints including right
shoulder, arm pain, hypertension. Initial diagnosis was rotator cuff degeneration.
Subsequent visits occurred with the attempt to manage the shoulder pain. Visit on 3/1/06
additionally established hyperlipidemia. And a periodontal infection in the upper gum
area. Anxiety and depression was noted, with the prescription of Lexapro 10 mg once a
day. Subsequent visits for upper respiratory infections are noted. On 12/29/06 migraine
headaches were diagnoses and the patient was given a trial of Topamax. It was noted that
her blood pressure was increasing and that she had increasing GERD.
2/6/06 (Rivera) – MRI brain: no evidence for acute trauma, few punctuate areas of high
signal within the white matter of the left frontal love, a nonspecific funding but may
represent ischemia white matter changes.
MRI Cervical Spine (5/16/06): Osteophyte complex noted at C5-6 and C3-4. At that
time the patient was s/p anterior cerical discectomy.
EEG 5/18/06 – Localized eplieptiform activity; sharp waves; left and right temporal
areas, sometimes lateralized on the left. Intermittent delta and theta waves, left and right
frontal area. The EEG was interpreted as and consistent with a potentially epileptogenic
cerebral dysfunction in the left and right temporal area that is lateralized to the left.
“Please correlate with the clinical information” Subsequently diagnosed with complex
partial seizure disorder.
Remarkable improvement in symptoms (70%) with original surgery with gradual
recurrence of symptoms.
March 2008 IME (Jones) – complaining of right trapezial to right periscapular
discomfort. Working in a sedentary position. Works as customer service rep for the City
of Cocoa. Missed three months work, but working at the same job as before the accident.
Once or twice in the record, mention is made of problems with cognition, but not early in
the postaccident course. Patient also suffers from depression, probably pre-existing.
Factors include father having been murdered in a carjacking in Puerto Rico, husband
killed in MVA, one of her sons dying from cancer, caring for her mother with AD in the
home (also cares for two children and a granddaughter. (2/08 – Gebel). Felt that accident
may have exacerbated the depression, but was certainly pre-existing.