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Baylor Saint Lukes Woodlands Neurosugery Elizabeth Vandergaag 17198 St. Lukes Way The Woodlands Tx 77384
Thomas E. Hiley 02/18/1952 4584
*****.******@*****.***
6922 Comanche Bend
Montgomery Tx 77316
Thomas E. Hiley
*****.******@*****.***
6922 Comanche Bend
Montgomery Tx 77316
02 / 24 / 2025
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Baylor St Luke's Medical Center
6720 Bertner Street, 4-292
Houston TX 77030
Hiley, Thomas E
MRN: 09295464, DOB: 2/18/1952, Legal
Sex: M
Visit date: 9/5/2024
Progress Notes by Elizabeth Vandergaag, NP at 9/5/2024 10:30 AM Author: Elizabeth Vandergaag, NP Service: Author Type: Nurse Practitioner Filed: 9/5/2024 11:11 AM Encounter Date: 9/5/2024 Status: Signed Editor: Elizabeth Vandergaag, NP (Nurse Practitioner) History and Physical
Patient ID: Thomas E Hiley
Date of Evaluation: 09/05/2024
Date of Birth: 2/18/1952
Primary Care Provider: No primary care provider on file. Chief Complaint: Back Pain and Neck Pain (Back/ neck pain MVA 7/2/2024) HPI: Thomas E Hiley is a pleasant 72 y.o. year old male that presents today for evaluation of neck and back pain after motor vehicle accident on July 2. Patient states he was rear-ended while driving and initially did not have significant pain so he returned home. Over the next 5 days pain gradually increased and he was seen in the emergency room at Houston Methodist on July 7. He had CT scans done that showed no acute fractures and was released home. He has been working with spine center since that time and having chiropractic adjustments. Symptoms have not improved. He notes constant posterior neck pain with associated headaches. He also has pain in his lower back. He does note some numbness and tingling in the hands occasionally as well as numbness that sometimes radiates down the right leg. No significant radicular pain and no weakness. No difficulty with balance or coordination and no acute loss of bowel or bladder control. He had an MRI completed and was referred to our office for further evaluation. Past Medical History:
Past Medical History:
Diagnosis Date
Prostate disease
Surgical History:
Past Surgical History:
Procedure Laterality Date
ELBOW SURGERY Left
KIDNEY STONE SURGERY
KNEE SURGERY Left
SHOULDER SURGERY
Social History:
reports that he has never smoked. He has never been exposed to tobacco smoke. He has never used smokeless tobacco. He reports that he does not use drugs. Family History:
Family history is unknown by patient.
Current Medications:
Generated by 83873 at 3/2/25 6:53 AM Page 1
Baylor St Luke's Medical Center
6720 Bertner Street, 4-292
Houston TX 77030
Hiley, Thomas E
MRN: 09295464, DOB: 2/18/1952, Legal
Sex: M
Visit date: 9/5/2024
Progress Notes by Elizabeth Vandergaag, NP at 9/5/2024 10:30 AM (continued) Current Outpatient Medications:
esomeprazole (NexIUM) 20 MG capsule, Take 1 capsule (20 mg total) by mouth daily., Disp:, Rfl: tamsulosin (FLOMAX) 0.4 mg cap 24 hr capsule, Take 2 capsules (0.8 mg total) by mouth nightly., Disp:, Rfl:
zolpidem (AMBIEN) 10 mg tablet, Take 1-2 tablets (10-20 mg total) by mouth every night as needed., Disp:, Rfl:
Allergies:
Allergies
Allergen Reactions
Alprazolam Hives
Other Reaction(s): Other (See Comments)
Betamethasone Hives
Codeine Nausea And Vomiting, Rash, Anxiety and Other
(See Comments)
Other Reaction(s): Dizziness
Propofol Hives
Other Reaction(s): Other (See Comments)
Tramadol Hives
Hydrocodone
Oxycodone Rash
Other Reaction(s): Dizziness, Dizziness
Physical Exam:
Vitals:
09/05/24 1029
BP: 117/83
Pulse: 76
Resp: 18
Temp: 98.3 F (36.8 C)
General: This is a well-developed well-nourished male in no acute distress. HEENT: Head atraumatic, normocephalic. Eyes PERRLA, EOMI. Oropharynx: clear, dentition intact. Neck: Well-maintained range of motion. Supple. No lymphadenopathy. Lungs: Breathing unlabored. No audible wheeze.
Abdomen: Soft, nontender.
Musculoskeletal: Moves all extremities well. Well-maintained range of motion through major joints. No deformity noted. Tenderness to palpation with muscle spasm present posterior cervical spine Neuro: Alert and oriented x3. Speech is fluent. Converses easily. Strength is 5/5 in bilateral upper and lower extremities. Sensation is slightly decreased to light touch in the left thumb, otherwise intact throughout. Gait is stable and unassisted. Able to stand on heels and toes. Tandem gait stable. Skin: Warm and dry. No lesions.
Review of Imaging and Diagnostic Studies:
MRI of the cervical and lumbar spine completed at alliance Spring imaging on August 26 were personally reviewed. There are multilevel degenerative changes noted in both the cervical and lumbar spine. In the cervical spine there is disc herniation at C3-4 resulting in left foraminal stenosis also mild to moderate bilateral Generated by 83873 at 3/2/25 6:53 AM Page 2
Baylor St Luke's Medical Center
6720 Bertner Street, 4-292
Houston TX 77030
Hiley, Thomas E
MRN: 09295464, DOB: 2/18/1952, Legal
Sex: M
Visit date: 9/5/2024
Progress Notes by Elizabeth Vandergaag, NP at 9/5/2024 10:30 AM (continued) foraminal stenosis at C5-6. In the lumbar spine there is a broad-based disc herniation as well as facet and ligamentous hypertrophy at L2-3 resulting in moderate central and bilateral foraminal stenosis. IMPRESSION:
1. MVA (motor vehicle accident), initial encounter 2. Neck pain, acute
3. Acute bilateral low back pain with right-sided sciatica 4. Tension headache
MEDICAL DECISION MAKING/PLAN:
Mr. Hiley presents with 2 months of neck and back pain following a motor vehicle accident in July. Overall exam his exam today is normal. He does have some intermittent numbness in bilateral hands on the right leg. I think he would benefit from a full course of physical therapy for the neck and back pain as well as tension headaches. I have also referred him to pain management for further evaluation. I would like him to follow-up with us in 8 weeks.
Body mass index is 26.18 kg/m .
BMI Plan: High BMI-Exercise counseling provided
Total time spent in reviewing records, imaging, patient evaluation, discussion and planning was 30 minutes. Elizabeth Vandergaag, ARNP
Progress Notes by Elizabeth Vandergaag, NP at 10/16/2024 9:30 AM Author: Elizabeth Vandergaag, NP Service: Author Type: Nurse Practitioner Filed: 10/16/2024 9:51 AM Encounter Date: 10/16/2024 Status: Signed Editor: Elizabeth Vandergaag, NP (Nurse Practitioner) Baylor College of Medicine Neurosurgery Clinic Progress Note Patient Name: Thomas E Hiley
Date of Birth: 2/18/1952
Date of Service: 10/16/2024
Primary Care Provider: No primary care provider on file. Chief Complaint: Follow-up for hand and foot numbness History:Thomas E Hiley is here today for follow-up, approximately 3 months out from his motor vehicle accident. He did complete 2 visits of physical therapy and is working on a home exercise program. He had 1 Generated by 83873 at 3/2/25 6:53 AM Page 3
Baylor St Luke's Medical Center
6720 Bertner Street, 4-292
Houston TX 77030
Hiley, Thomas E
MRN: 09295464, DOB: 2/18/1952, Legal
Sex: M
Visit date: 10/16/2024
Progress Notes by Elizabeth Vandergaag, NP at 10/16/2024 9:30 AM (continued) visit with Dr. Yancey but no injections or interventions. He states that overall his symptoms have improved. He still has some aching type pain. He is most bothered by numbness and tingling in his right hand and his right foot. He does not note particular weakness or any radicular pain. Past Medical History: The patient's past medical history is reviewed and updated. Past Medical History:
Diagnosis Date
Prostate disease
Exam:
Vitals:
10/16/24 0931
BP: 123/85
Pulse: 77
Resp: 18
Temp: 97.6 F (36.4 C)
General: This is a well developed, well nourished male in no acute distress. Musculoskeletal: Moves all extremities well. No atrophy noted. Neuro: Alert and oriented x3. Speech is fluent. Follows commands bilaterally. Strength is 5/5 in bilateral upper and lower extremities. Sensation decreased to light touch throughout the right hand up to the wrist and in the right foot, otherwise intact throughout.
Gait is stable and unassisted. No dropfoot.
Imaging: MRI of the cervical and lumbar spine completed at alliance Spring imaging on August 26 reviewed at his last visit and showed multilevel degenerative changes noted in both the cervical and lumbar spine. In the cervical spine there is disc herniation at C3-4 resulting in left foraminal stenosis also mild to moderate bilateral foraminal stenosis at C5-6. In the lumbar spine there is a broad-based disc herniation as well as facet and ligamentous hypertrophy at L2-3 resulting in moderate central and bilateral foraminal stenosis. Impression:
1. Intermittent tingling sensation of right hand and foot Medical Decision Making and Plan:
1. Mr. Hiley has ongoing numbness and tingling in his right hand and right foot. These are in a nondermatomal distribution. No associated weakness. We did discuss that the neck step would be an EMG for further evaluation. At this point he states his symptoms are not that bothersome and he would like to wait and see how he does.
2. He will contact the office if he has ongoing or worsening symptoms and we can order an EMG and see him for follow-up.
3. New orders today include: None
A total of 20 minutes was spent on patient care including review of previous medical records and imaging, Generated by 83873 at 3/2/25 6:53 AM Page 4
Baylor St Luke's Medical Center
6720 Bertner Street, 4-292
Houston TX 77030
Hiley, Thomas E
MRN: 09295464, DOB: 2/18/1952, Legal
Sex: M
Visit date: 10/16/2024
Progress Notes by Elizabeth Vandergaag, NP at 10/16/2024 9:30 AM (continued) patient evaluation, education and treatment planning. Elizabeth Vandergaag, NP
END OF REPORT
Generated by 83873 at 3/2/25 6:53 AM Page 5
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