UNIVERSIDAD CATÓLICA REDEMPTORIS MATER

Technical English 2

Unit 8 Orthopedic
Admission note

Name: Sthefany González Silva

 Admission note
Patient Name: Cesar González
Age: 45 years
Sex: Male
Date of MRI: April 15, 2023

Medical History:

Cesar González is a 45-year-old male patient who consulted a doctor due to a chronic lower back pain
that he had been experiencing for approximately two years. The patient reported that initially the pain
was mild and occasional, but in the recent months it had become more intense and constant, limiting his
daily activities.

S: Low Back pain for 2 years

O: Consciousness clear.

Vital signs: T: 36.3° P: 85/min R: 18/min BP: 110/80 mmHg

When performing a physical examination, the Lasègue test came out positive.

A: MRI Findings:
The MRI revealed the presence of a disc herniation at the L4-L5 level, located on the right side of the
lumbar spine. A protrusion of the intervertebral disc was observed, compressing the corresponding nerve
root at that level.

P:
- Lumbar endoscopic discectomy
-Analgesic and anti-inflammatory
- Avoid strenuous physical activities
- Rehabilitation and physical therapy
Based on the results of the MRI, Cesar González was diagnosed with a right lumbar disc herniation at
the L4-L5 level. I determined that it was necessary to perform a lumbar endoscopic discectomy to treat
and alleviate the compression on the nerve root. Analgesic and anti-inflammatory medications were
prescribed to relieve the pain, and patient was advised to avoid strenuous physical activities that could
worsen his condition. A follow-up appointment was scheduled to discuss the results of the lumbar
endoscopic discectomy and establish a plan for post-procedure rehabilitation and physical therapy.
Unknown words
The Lasègue sign or Lasègue test is a test done during a physical examination to determine if a patient with low
back pain has a herniated disc, usually located in L5 (fifth lumbar spinal nerve).