HISTORY AND PHYSICAL EXAMINATION

PATIENT NAME: Deanna Martinez

PATIENT ID: 117232

ROOM NO.: 425

DATE OF ADMISSION: 05/26/----

ADMITTING PHYSICIAN: Sheila Goodman, MD, Neurosurgery

ADMITTING DIAGNOSIS: Questionable herniated disk.

CHIEF COMPLAINTS: Lower back pain, 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 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 that 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.

PAST HISTORY is significant for a cesarean section 20 years ago, otherwise

negative except as in HPI.

ALLERGIES: Some environmental allergies. No known drug allergies.

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HISTORY AND PHYSICAL EXAMINATION

Patient Name: Deanna Martinez

Patient ID: 117232
Admission Date: 05/26/----
Page | 2

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. 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.

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HISTORY AND PHYSICAL EXAMINATION

Patient Name: Deanna Martinez

Patient ID: 117232
Admission Date: 05/26/----
Page | 3

PLAN
1. Admit patient to Neurosurgery Services.
2. Obtain a lumbar myelogram. If the myelogram confirms the disk
herniation, proceed with discectomy 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:xx
D: 05/26/----
T: 05/27/----

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