Woodland Memorial Hospital
225 Main Street, Anywhere AL 12345
Office: (555) 123-4567
SPINE CLINIC HPIP
Patient: Jack P. Strong
Patient ID: 007321
PCP: Jesse D. Smith, MD
DOB: 15, May 1961
AGE: 55
Sex: Male
Date of Exam: 31, August 2014
HISTORY: Jack presents today after being treated with lumbar decompression for cauda equina syndrome.
The patient was noted on presentation to 0/5 motor strength of the EHL in the S1 distribution on the right lower
extremity, primarily. At that time, he was noted to have mild overflow incontinence and inability to have a
bowel movement. The patient reports that since his surgical intervention and decompression, he has had
progressive recovery of his right EHL function. He continues to have difficulty with push-off on the right lower
extremity. He reports that he is able to urinate without difficulty and has normal control of his bowels as well.
PHYSICAL EXAM: Does reveal continued weakness in the right L5-S1 distribution with EHL strength of 1/5,
which is improved from a previous 0/5 function. He also has normal sensation along the perianal region and 2/5
motor strength of the right gastrocsoleus complex. The peroneals are noted to be 1/5. The patient has a negative
straight-leg raise. His wound appears to be healing well.
IMPRESSION: Status post cauda equina syndrome secondary to large lumbosacral disk herniation, status post
decompression.
PLAN: Secondary to Jack’s slow improvement, I have recommended he continue to slowly reengage in
activities. He has been provided a handout for core strengthening, lumbar stabilization, and proprioceptive
strength training.
Follow up with me in 6 weeks to assess response. He is advised to avoid soaking his wound until 2 small areas
of suture abscess completely heal over. Otherwise, patient appears to be noting some slow neurologic
improvement from his surgery.
_________________________
Jesse D. Smith, MD, Orthopedic Surgery
JDS:vw
D: 8/13/2014
T: 8/13/2014