HISTORY: This 40-year- old black Latin female was addimited for low back and right lower extermities symptoms. She had been suffering from intermittent low back pain dating back to an NVA in 2000. In Dec of last year, she started a job where she was doing a job with lot of heavy lifting. Shortly after that she began experiencing a pain in her back and right leg. CT scan was done that showed questionable disk buldging.
This was follwed by a Mylogram that showed no definate deffect. However, repeat CT showed knocked compression at the L 4-5 level some legamentum flavum promience and low graded disk buldging. On May 27, the patient underwent a Lumbardisectomy at L5S1 on the right side and a disk herniation was identified at the time of surgary. Post opreatively, the patient had rsolution of her low back pain and right leg symptems and was dealing reasonably well at the time of discharge. She remain a febral through out her hospital course. Incision was healing nicely and she was ambulating without any difficulty.
DISCHARE DIAGNOSIS: Herniated disk L5S1 right.
DISPOSITION: Discharged to home. The paitient and her husband were given detailed written instructions as to her activities and limitations. I will follow her in my clinic in six weeks of time and I have advised her to stay off work untiil that time. She was given a pricription for Tylenol with Codeine P.R.N. pain . She was advised that if any problems develop i.e. high fever, nausea, vomiting, headache or blurred vision, she just come to clinic earlier or repoprt to Hillcrest emergency room.
DOCTOR: THOMAS BURGOS.