Case Study 6 Discharge

Topics: Spinal disc herniation, Symptoms, Low back pain Pages: 1 (318 words) Published: October 28, 2014

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: 6/07/----
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