EFTA00283009.pdf

JENNIFER L. SOLOMON, M.D. SPINE AND SPORTS MEDICINE HOSPITAL FOR SPECIAL SURGERY 429E.75 TH STREET, 4 TH FL. NEW Y 2 TEL: FACSIMILE TRANSMITTAL SHEET TO FROM: Ada Mojica t--- Sv• Crtt-51% COMPANY: J DATE: FAX NUMBER: TOTAL NO. OF PAGES INCLUDINGCOVER: t eMke ') '•CCICTh PHONE NUMBER: SENDER'S PHONE NUMBER: RE: SENDER'S FAX NUMBER: c...?s\-cac\ OURGENT OPOR REVIEW O PLEASE COMMENT OPLEASE REPLY O PLEASE RECYCLE NOTES/COMMENTS: COOILOOd snOZ:E0 9lOt 8 ere 6L68L6/9103:88A NON013S '80 EFTA00283009  Epstein, Jeffrey j filste, V2Wi63183) I tC, 79674229 I CtiOrtt•stber.40611 .40 HOSPITAL FOR IIM SPECIAL SURGERY Jennifer L. Solomon, M.D. Spine and Sports Medicine Hospital for Special Surgery 535 EAST 70th STREET NEW Tele: Name: Jeffrey Epstein DOB: 1/20/1953 Age: 63 Date of Visit: 7/7/2016 Referring Physlcian:Jennifer L Solomon CHIEF COMPLAINT: Intermittent tingling bilateral lower extremities. HISTORY OF PRESENT ILLNESS: This is a 63-year-old gentleman who presents today for initial consultation regarding a several-year history of intermittent numbness and tingling. He has no pain. He denies any progressive weakness. bowel dysfunction. He denies any change in his quality of life. ALLERGIES: No Known Allergies Confirmed - 07/07/10 9:08:38 AM EST Fccinal He fiscal • Ewen, Jetty Page 3 of6 E00/Z00d u00Z:E0 9L OZ 9 Me xei N0WIES '80 EFTA00283010  Ep:toi- . Jeffrey Mgt 1/20,103(63) ) 179874229 I ChaelNureet.10011 PAST MEDICAL HISTORY: Edema and parathyroid issues. PAST SURGICAL HISTORY: Appendectomy. ALLERGIES: He denies allergies to medications. FAMILY HISTORY: Diabetes. REVIEW OF SYSTEMS: Denies any weight loss, fevers, chills, bowel or bladder dysfunction. SOCIAL HISTORY: He exercises moderately. He is single. PHYSICAL EXAMINATION: He is 5'11". 175 lb, blood pressure 117/61, pulse 51. The patient presents today in no acute distress, alert and oriented x 3. Cervical range of motion is full. Lumbar range of motion is full. Strength is 5/5. Sensation is grossly intact. Reflexes are symmetric. No evidence of muscle atrophy, asymmetry or fasciculations. RADIOGRAPHS: Radiographic evaluation shows grade I spondylolisthesis at 4-5 with spinal stenosis. IMPRESSION: Spinal stenosis. PLAN: At this time we reviewed all of his findings. We reviewed his films and surgical and nonsurgical options. At this time I would 02A, trial of Neurontin to see if we can decrease some of his symptoms. We discussed this at great length. Follow up on a basis. PROBLEM LIST: Spinal Stenosis Lumbar Region Dictated by: Jennifer L. Solomon, cc: Dr. Bruce Moskowitz. Formal Heath Record • Email% Jeffrey Page40f6 COG/C00d 91.0t 8 811 fi xed N0N0IDS •aa EFTA00283011