Holly H.

Main

Jurisdictional

Lower Back DO

MRI of Lumbar Spine (Ex. 1F)

12/7/10 - 12/8/10

Desiccation only of L4/5, central disc herniation. Disc bulge of the L5/S1 disc.

Positive Straight Leg Raise (Grossinger)

10/4/2011 - 10/5/11

Notes SLR positive at 75 degrees on the right.

EMG of Lower Back (Grossinger)

10/4/11 - 10/5/11

EMG revealed denervaion, and indicated r. L5 radiculopathy

MRI (Kunitz)

3/21/12 - 3/22/12

Progressive degeneration of the L4-5 disc, now moderate, with minimal diffuse disc osteophyte complex. Minimal inferior narrowing of both L4-5 neural foramina secondary to small diffuse disc osteophyte complex.

Medication(Kuznits)

5/4/12 - 5/5/12

Now taking Oxycontin

Complaints

5/24/2012 - 5/25/2012

Main complaint is back and bilateral leg pain that has been worsening. Done well from a C6-7 anterior cervical fusion

Back Surgery

5/29/12 - 5/30/12

Claimant underwent a left hemilaminectomy and facetectomy with left L4-5 diskectomy, L4-5 interbody fusion; L4-5 left posterolateral fusion. This to treat her L4-5 central herniated disk, L4-5 lateral recess stenosis, L4-5 degenerative disk.

Neck DO

MVA

9/29/10 - 9/30/10

Claimant went to Springfield Hospital following being rear-ended by another vehicle. She complained that her entire body hurt on the right side, On physical examL tenderness present midline on neck, most prominent at C3-C4; pain in motion of right shoulder.

Cervical MRI (Ex. 1F)

12/07/10 - 12/08/10

Impression: At C6-7 there is a small central herniation without cord impingement; Left paracentral disc bulge at C7/T1.

Complaints of Dropping things With R. Hand (Ex. 1F)

12/22/10 - 12/23/10

Complained to primary doctor, he referred her to neurologist.

Medications (Grossinger)

10/4/11 - 10/5/11

Percocet, Naprosyn, Flexeril, (and Geodon for BiPolar)

Complaints (Grossinger)

10/4/11 - 10/5/11

Complains of low back pain radiating to the r. lower extremity with discomfort in hip and thigh, as well as numbness in both legs and feet.

Recurring headaches.

Difficulty with memory and blurring of vision. Pain is debilitating. Numbness in the right side of her face, numb feeling in hands. Trouble completing sentences due to memory distrubances, requires calendar and reminder book. Headaches 4-5 times a week. (Headaches supported by MRI of brain which showed non-specific punctate white matter changes felt to be consistent with migrains).

Physical Exam w/Neuro (Grossinger)

10/26/11 - 10/27/11

Dr. Grossinger notes that on exam, claimant's cervical range of motion was restricted with sidebending androtation bilaterally. Sensation is reduced along the lateral aspect of the arms.

EMG of Neck (Grossinger)

10/26/11 - 10/27/11

EMG revealed denervation, and indicated bilateral C6 radiculopathy.

C6-C7 Anterior Cervical Diskectomy & Fusion

11/21/11 - 11/22/11

Claimant underwent surgery for a Central disk herniation at the C6-C7 level

Pre-Admission History (Paoli Hospital)

11/21/11 - 11/22/11

Notes that claimant had a chief complaint of neck and right arm pain subsequent to two motor vehicle accidents (2005 & 2010). Pain was described as sharp, stabbing pain radiating from neck into right scapula and shoulder area and further down the right arm involving the tricep, elbow, dorsi form, and parasthesias of the thumb, index and middle finger.

Recurrence of Neck & Arm Pain (Kunitz)

3/16/12 - 3/17/12

Chief complaint of neck and right arm pain, headaches and low back and bilateral leg pain. Did relatively well post-op but around a month and a half ago (January 2012) developed recurrent neck and right arm pain. Currently reports constant pain and paresthesias involving the neck, scapula, r. arm invloving the bicep and radial forearm with pain into the hand by the bottom portion of the thumb.

Also reports constant diffuse headaches.

Physical Examination: Normal motor, but loss of sensaion on top of left foot, right interior thigh, and right and dorsal forearm.

SLR positive bilaterally.

Shoulder DO

Mental Health

Lyme Disease

Possible Positive Lyme Disease Test (Ex. 1F)

4/6/11 - 4/7/11

Headaches

MRI of Brain (Ex. 1F)

4/4/11 - 4/5/11

Impression: Several nonspecific punctate subcortical white matter signal abnormalities. Symptoms: Headaches, dizzyness, hearing loss and visual disturbances.