Hillcrest Case 6 H&P

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  • Topic: Spinal disc herniation, Human leg, Low back pain
  • Pages : 3 (605 words )
  • Download(s) : 605
  • Published : April 13, 2013
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HISTORY AND PHYSICAL EXAMINATION (H&P)

Patient Name: Deanna Martinez

ID No.: 117232

Room No.: 425

Date of Admission: 05/26/----

Admitting Physician: Sheila Goodman, MD Neurosurgery

Admitting Diagnosis: Questionable herniated disk

Chief Complaint: low back pain, right leg pain.

HISOTRY OF PRESENT ILLNESS: This 40-year-old Latin female presents with complaints of low back and right leg pain she said that she hurt her back in a motor vehicle accident three years ago and she has had a history of intermittent low back pain since that time. Last December she started a job where she had to lift boxes that weighed approximately 40 pounds. Around the first of January this year she began to complain of back pain that gradually went into her right leg the pain is primarily in the sacral iliac region and radiates into the buttock and lateral lower leg as far as the ankle. She has no numbness, coughing and sneezing exacerbates her pain. She has to move around to get comfortable when lying down, but she is more comfortable lying down than in any other position. She’s still working fulltime but is not doing the heavy lifting at this time. She has been going to a Chiropractor for the last two months with no pain relief. She’s taken Flexeril, Norflex, Tylenol with codeine and Darvocet, all of these have failed to improve her symptoms. She had a CT scan done recently and we are getting those results.

PAST HISTORY: Significant for a cesarean section 20-years-ago, otherwise negative expect as in HPI

ALLERGIES: Some environmental allergies, no known drug allergies.

FAMILY HISTORY: The patient was adopted and does not know her family history. She lives with her husband; she has one son living and well who is in the military.

SOCIAL HISTORY: Denies x 3. No blood transfusion in the past.

PHYSICAL EXAMINATION: This well-developed, well-nourished, thin, pleasant, 40-year-old Latin female is in some distress due to pain. HEENT: The patient...
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