Hillcrest Case 6 H&P Essay

602 Words Apr 4th, 2013 3 Pages
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
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Breasts: no masses, no nipple retraction, no discharge. Heart: S1 and S2, no gallops, rubs, or murmurs appreciated. Abdomen is scaphoid, soft and non-tender with positive bubble sounds. Pelvic/ Rectal: deferred as patient has recently visited her GYN for a routine Pap smear. Neurologic exam reveals normal motor strength in all muscle

HISTORY AND PHYSICAL EXAMINATION

Patient Name: Deanna Martinez
ID No.: 117232
Date of Admission: 05/26/----
Page 2

groups of her lower extremities bilaterally. Sensory exam is normal to pin prick and light touch throughout her lower extremities bilaterally. She has 2+ knee and angle jerks bilaterally. Straight leg raising is accomplished at 90° on the left, however on the right patient complains of low back and leg pain at 60°.

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 arthropathy. I’m not 100% certain that what we see on the CT scan is the etiology of her present symptoms. I would like to have a myelogram prior recommending surgical intervention.

PLAN:
1. Admit patient to neurosurgery services
2. Obtain a lumbar myelogram. If the myelogram confirms the disk herniation procedure with discectomy the following day.
3. Plan was discussed with the patient and her husband; there were no barriers to

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