EXAMPLE
Emeka Nchekwube, M.D.
PREOP H&P
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HISTORY OF PRESENT ILLNESS: The patient is a 48-year-old man
being admitted for an anterior cervical discectomy, fusion, and
internal stabilization for cervical disk herniation of C5-C6 and
C6-C7.
The patient was involved in a work-related injury on 07/27/2004,
during which he was struck in the head by a forklift front-loader
with a heavy load, which crushed him between two loads causing
both neck and low back injuries. The patient developed neck pain
radiating down the upper extremities and low back radiating down
the right lower extremity. He has been treated extensively with
a conservative regimen since his injury to no avail. He has
developed progressive symptomatology in the last several months.
A recent MRI study showed the cervical disk herniation at C5-C6
and C6-C7 with thecal encroachment.
PAST MEDICAL HISTORY: He has a prior history of sleep apnea
currently treated with apnea machine. He also has a history of
hypertension well controlled on medication.
PAST SURGICAL HISTORY: He denied any prior surgeries.
ALLERGIES: He has no known allergies.
CURRENT MEDICATIONS: Vicodin.
PHYSICAL EXAMINATION: GENERAL APPEARANCE: The patient was
ambulatory with a normal gait. HEAD AND NECK: Revealed moderate
paracervical muscle spasm with about a 15- degree loss of range
of motion in all directions. Ears, nose, and throat were clear.
CHEST: Clear. HEART: Revealed normal sinus rhythm. ABDOMEN:
Soft and benign. EXTREMITIES: Revealed no visible atrophy or
fasciculation. Straight leg raising was positive bilaterally at
40 and 60 degrees on the right and left respectively.
NEUROLOGIC: He had decreased pinprick sensation over the
distribution of C6 and C7 on the right and there was very mild
blunting of pinprick sensation over C5 on the right as well.
Motor examination revealed weakness of grip with an estimated
strength of grade 4/6 on the right. Reflexes were symmetrical
and hypoactive at 1+ with no pathologic component. MENTAL
STATUS: Cranial nerves and cerebellar examinations were normal.
IMPRESSION:
1. Cervical disk herniation C5-C6, C6-C7 with cervical
radiculopathy.
2. Lumbar disk herniation L4-L5, L5-S1.
PLAN: The patient will undergo anterior cervical discectomy and
fusion. The procedure, risks, and complications were discussed
with the patient.