Hillcrest Medical Case 6
HISTORY AND PHYSICAL EXAMINATION or EMERGENCY DEPARTMENT TREATMENT RECORD Patient Name: Lydia Cruz Patient ID:DOB:Age:40Sex: F Hospital Number: 11723 Room No. : 425 Date of Admission/Date of Arrival: 05/26/2012 Admitting/Attending Physician: Tomas Burgos, MD Admitting Diagnosis: Questionable Herniated disk. Chief Complaint: Low back pain, right leg pain. HISTORY OF PRESENT ILLNESS: This 40-year-old black Latin female presents with complaints of low back and right leg pain. She says that she hurt her back in a motor vehicle accident in 2000 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 weight 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 sacroiliac region and radiates into the buttock and lateral lower leg as far as the ankle. She has no numbness. Coughing and sneezing exacerbate her pain. She has to move around to get comfortable when lying down but she is more comfortable lying down then in any other position.
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She is still working full-time but is not doing the heavy lifting at this time. She has been going to a chiropractor for the last 2 months with no pain relief. She is taking Flexeril, Norflex, Tylenol with Codeine, and Darvocet. All of these have failed to improve her symptoms. She had a CT scan done recently. PAST HISTORY: A cesarean section in 1990. 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. SOCIAL HISTORY: Denies x3. Continued) BLOOD TRANSFUSIONS: None. PHYSICAL EXAMINATION: This well-developed, well-nourished, thin, pleasant, black, 40 year-old female is in no acute distress. HEENT: The patient wears dentures, otherwise normal. NECK: Subdual, no JVD, no lymphadenopathy. LUNGS: Clear. BREASTS: No masses, no nipple retraction or discharge. HEART S1 and S2: No gallops, probs, or murmurs depreciated. ABDOMIN: Scaphoid, soft, and non tender with positive bowel sounds. PELVIC AND RECTAL: Differed as patient has recently visited her GYN for a routine pap smear.
NUEROLOGIC EXAM: Normal motor strength in all muscle groups of her lower muscles bilaterally. SENSORY EXAM: Normal to pinprick and light touch throughout her lower extremities bilaterally. LOWER EXTREMITIES: She has 2+ knee and ankle jerks bilaterally. Straight leg raising is accomplished to 90 degrees on the left. However, on the right patient complains of low back pain and leg pain at 60 degrees. IMPRESSION: This patient has a long history of low back pain which seems to have become radicular in January of this year. She did have a CT scan that showed what appeared to be a small disk herniation at L5 S1.
She also has a considerable amount of facet othropocy. I am not 100 percent certain that what we see on the CT scan is the etiology of her present syndromes and I would like to have a myelogram prior to recommending surgical intervention. (Continued) PLAN: Admit patient to Neurosurgery service. Obtain a lumbar myelogram. If the myelogram confirms the disk herniation, proceed with discectomy the following day. This plan was discussed with the patient and her husband who understood and agreed. _________________________ Tomas Burgos, MD TB:xxx D:05/26/2012 T:10/17/2012