DISCHARGE SUMMARY

PATIENT NAME
Deanna Martinez

PATIENT ID
117232

DATE ADMITTED
05/26/2019

DATE DISCHARGED
06/07/2019

SURGEON
Shelia Goodman, MD.

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
discectomy at L5-S1 on the right side, and a disc 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.
Patient Name: Deanna Martinez
Patient ID: 117232
Date Admitted: 05/26/2019
Date Discharged: 06/07/2019
Page 2

DISCHARGE DIAGNOSIS
A 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 six weeks, and I have advised her to stay off work until that time.
No lifting. She was given a prescription for Tylenol with codeine p.r.n. pain.

She was advised that if any problems develop, i.e., fever, nausea, vomiting,
headache, or blurred vision, she is to come to the clinic earlier or report to
Hillcrest emergency room.

__________________________
Sheila Goodman, MD
Neurosurgery

SG: hw
D: 06/08/2019
T: 06/10/2019