HISTORY AND PHYSICAL EXAMINATION

PATIENT NAME
Deanna Martinez

PATIENT ID
117232

ROOM NUMBER
425

DATE OF ADMISSION
05/26/----

ADMITTING PHYSICIAN
Sheila Goodman, MD, Neurosurgery

ADMITTING DIAGNOSIS
Questionable herniated disk.

CHIEF COMPLAINTS
1. Low back pain.
2. Right leg pain.

HISTORY OF PRESENT ILLNESS

This 40-year-old Latin female presents with complaints of low back and right
leg pain. She says that she hurt her back in a motor vehicle accident 3 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 1st 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 than in any other position.
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, and we are getting those results.

(Continued)
HISTORY AND PHYSICAL EXAMINATION

Deanna Martinez
117232
05/26/----

Page 2

PAST HISTORY
Significant for a caesarian section 20 years ago, otherwise negative except
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 x3. No blood transfusions 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 wears dentures,
otherwise normal. NECK is supple, no JVD, no lymphadenopathy. LUNGS are
clear bilaterally. BREASTS: No masses, no nipple retraction, no discharge.
HEART: S1 and S2. No gallops, rubs, or murmurs appreciated. ABDOMEN is
scaphoid, soft, and nontender with positive bowel 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 groups of
her lower extremities bilaterally. Sensory exam is normal to pinprick and
light touch throughout her lower extremities bilaterally. 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 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.

(Continued)
HISTORY AND PHYSICAL EXAMINATION

Deanna Martinez
117232
05/26/----

Page 3

She also has a considerable amount of facet arthropathy. I am 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 to recommending surgical
intervention.

PLAN
1. Admit patient to Neurosurgery Services.
2. Obtain a lumbar myelogram. If the myelogram confirms the disk
herniation, proceed with diskectomy the following day.
3. Plan was discussed with the patient and her husband. There were no
barriers to communication. They understood and agreed. Informed consent
was obtained.

______________________________________
Sheila Goodman, MD
Neurosurgery

SG:JO
D: 05/26/----
T: 05/27/----