Preview

Case Study 6 Discharge

Satisfactory Essays
Open Document
Open Document
318 Words
Grammar
Grammar
Plagiarism
Plagiarism
Writing
Writing
Score
Score
Case Study 6 Discharge
DISCHARGE SUMMARY
Patient Name: Deanna Martinez
Patient ID: 117232
Date Admitted: 5/26/----
Date Discharged: 6/07/----
Surgeon: Shelia Goodman, MD, Neurosurgery
Consultation: None.
Procedure: Lumbar laminectomy.
Complications: None.
Admitting Diagnosis: Low back and right leg pain. Questionable herniated disk.
BRIEF HISTORY: This 40-year-old Latin female was admitted for low back and right lower extremity symptoms. She had been suffering from intermittent low back pain dating back to an MVA several years ago. In December of last year she started a job where she was doing a lot of heavy lifting. Shortly after that she began experiencing pain in her back and right leg. CT scan was done that showed questionable disk bulging. This was followed by a myelogram that showed no definite defect. However, repeat CT showed marked compression at the L4-5 level. Some ligamentum flavum prominence and low-grade disk bulging. On May 27, the patient underwent a lumbar diskectomy at L5-S1 on the right side and a disk herniation was identified at the time of surgery. Postoperatively the patient had resolution of her low back pain and right leg symptoms and was doing reasonably well at the time of discharge. She remained afebrile throughout her hospital course. Her incision was healing nicely and she was ambulating without difficulty.
DISCHARGE DIAGNOSIS: Herniated disk L5-S1 right.
DISPOSITION: Discharged to home. The patient and her husband were given detailed written instructions as to her activities and limitations. I will follow her in my clinic in 6 weeks’ time and I have advised her to stay off work until that time. No lifting. She was given a prescription for Tylenol with codeine PRN pain. She was advised that if any problems developed i.e. fever, nausea, vomiting, headache or blurred vision she is to come to clinic earlier or report to Hillcrest Emergency Room.
______________________________
Shelia Goodman, MD, Neurosurgery
SG:CFD: 6/07/----
T:

You May Also Find These Documents Helpful

  • Satisfactory Essays

    Clinical Information: Colon pervious CT evidence of disk bulging. Patient with lower back and right leg pain.…

    • 250 Words
    • 1 Page
    Satisfactory Essays
  • Better Essays

    B) was brought into the emergency room for pain to left leg and left hip. The injury occurred when the patient had a fall due to him losing his balance after tripping over his dog. The hospital is a 60 bed rural hospital located in Mr. B’s hometown. Mr. B was brought in by his son and neighbor. Upon triage Mr. B was complaining of pain 10/10 on the numerical pain scale and his vitals were found to be stable. Mr. B has a history of impaired glucose tolerance, prostate cancer, and chronic pain which he is on oxycodone. The Patient states he had no known allergies or previous falls. Upon the nursing assessment Nurse J. has noticed that the patient has limited range in motion, his left leg has swelling and appears shortened in comparison to the right. Nurse J. has informed the ED physician which he came to his bedside for…

    • 2877 Words
    • 12 Pages
    Better Essays
  • Good Essays

    11/16/15 Progress note indicated that the patient has constant pain. He has burning, stabbing pain in the right lateral elbow. He has difficulty in making a full fist. It takes a long time to release with the use of hot water, if he does make a fist. The pain radiates from his shoulder down to his right thumb, index and middle fingers. Pushing, pulling, reaching and turning doorknob aggravate the pain. Pain medications…

    • 594 Words
    • 3 Pages
    Good Essays
  • Satisfactory Essays

    Discharge summary Case 1

    • 225 Words
    • 2 Pages

    Patient presented to the emergency room, complaining of vaginal bleeding with pain in the lower pelvic area. Ultrasound preformed in the emergency room showed a 13.8 cm left adnexal mass with positive cardiac activity, Compatible with ectopic pregnancy.…

    • 225 Words
    • 2 Pages
    Satisfactory Essays
  • Powerful Essays

    Proofreader #1

    • 404 Words
    • 2 Pages

    HISTORY OF PRESENT ILLNESS: The patient is an elderly mail who fell 4 days prior to admission. He noted immediate pain and swelling in the area just below his left elbow. He was presented to the emergency room for treatment.…

    • 404 Words
    • 2 Pages
    Powerful Essays
  • Good Essays

    Lmbar Pain Case Study

    • 403 Words
    • 2 Pages

    DOI: 07/31/2009. Patient is a 50-year-old male maintenance technician who sustained injury to his back while pushing garage bin into the bin area. The patient was subsequently diagnosed with spinal stenosis, lumbar region, with neurogenic claudication; other intervertebral disc degeneration; and radiculopathy, lumbar region. As per OMNI notes, the patient is diagnosed with history of right L5-S1 tear, low back pain, right quadratus lumborum strain, and paresthesias. He underwent lumbar laminectomy at L5-S1, and L3-L4 and L4-L5 decompression of the nerve root on 2/24/2016. As per progress report dated 6/6/2016, the patient complains of lumbar pain. He states that the symptoms are mild. The pain is aggravated by extended walking. He returns after 3 months postoperative…

    • 403 Words
    • 2 Pages
    Good Essays
  • Satisfactory Essays

    Based on the medical report dated 02/02/16 by Dr. Schwartz, the patient presents with severe post-operative low back pain and stiffness/tightness and intermittent spasms and referred numbness/tingling into both legs, left greater than the right with intermittent tightness and spasms. She still walks with a limp and easily fatigues. Patient has intolerance to prolonged sitting/standing positions and ambulation of short distances and stair activities. IW is awaiting replacement of lumbosacral orthosis and transcutaneous electrical nerve stimulation (TENS) unit. She takes Zorvolex for post-operative pain management. Pain is rated as 70/100 mm scale. IW maintains post-operative home exercises.…

    • 411 Words
    • 2 Pages
    Satisfactory Essays
  • Better Essays

    broken hip with answer 4

    • 1761 Words
    • 5 Pages

    Physical Examination: The patient was alert, oriented to time, place, and date, and was responding appropriately to questions despite being in considerable pain. There were no signs of trauma to the head, neck, torso, arms, or left leg. The right thigh and hip were extremely tender and were immobilized by a leg splint. Heart and lung sounds were normal, and abdominal sounds were reduced.…

    • 1761 Words
    • 5 Pages
    Better Essays
  • Satisfactory Essays

    the client and his counselor met for his 1x1 session to discuss the six components of his treatment plan and to dress any issues with client reaching his treatment goals. The client at this time has been in compliance with this treatment goals. (legal)The client is working towards getting his license back, being a support to his mother while she goes to court to custody of his daughter. The client reported that he will seek custody of his daughter in future when he is stable enough to take care of her. Client reported that he still has plans on going to sober living . The client at this time appears to serious about getting clean and sober. The counselor will meet with client next week to complete his discharge planning…

    • 131 Words
    • 1 Page
    Satisfactory Essays
  • Satisfactory Essays

    Per office notes dated 03/23/2016, the patient complained of neck, right shoulder and right upper extremity pain. Physical therapy was helpful for the aching pain in her shoulder, forearm, and wrist. She also has stiffness in the neck. She also had learned biofeedback and progressive muscle…

    • 364 Words
    • 2 Pages
    Satisfactory Essays
  • Satisfactory Essays

    The applicant requests an upgrade of his general, under honorable conditions discharge to honorable. The applicant states, in effect, he served for eight years in the Army, he was diagnosed with post-traumatic stress disorder (PTSD), asthma, and had spinal back surgery. The applicant contends his command was attempting to give him an Article 15, he decided to go to a court-martial to beat the case; however the command bought up bar fight that happen three earlier, and he was not sure if he can win his case so he decided to request for discharge in lieu of trial by court-martial (Chapter 10). The applicant further contends he did not want to jail and when the fight occurred three earlier there was not enough evidence to charge him and the…

    • 132 Words
    • 1 Page
    Satisfactory Essays
  • Satisfactory Essays

    proofreading

    • 372 Words
    • 2 Pages

    HISTORY OF PRESENT ILLNESS: The patient is an elderly female who fell four days prior to admission. He noted immediate pain and swelling in the area just below his left elbow. He presented to the emergency room for treatment.…

    • 372 Words
    • 2 Pages
    Satisfactory Essays
  • Powerful Essays

    According to Equal Employment Opportunity (EEO) law constructive discharge is present when the employer is forcing an employee to resign by making the work environment so intolerable that a reasonable person would not be able to stay. As a legal term “reasonable person” is a hypothetical person in society who exercises average care, skill, and judgment in conduct. (Farlex, Inc., 2013)…

    • 1703 Words
    • 7 Pages
    Powerful Essays
  • Powerful Essays

    Elderly Trauma Patient

    • 4640 Words
    • 19 Pages

    The patient was alert and complaining of left lower extremity pain and abdominal wall pain. Advanced imaging revealed complex…

    • 4640 Words
    • 19 Pages
    Powerful Essays