EXAMPLE
Emeka Nchekwube, M.D.
PREOP H&P
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CHIEF COMPLAINT: The patient is a 39-year-old lady being admitted
for lumbar laminectomy and discectomy for lumbar disc herniation.
HISTORY OF PRESENT ILLNESS: The patient reported that she
developed low back pain on about 8/21/2005 with radiation down
the left leg. There was no specific antecedent event. It is
aggravated by almost all physical activities, especially for long
sitting, twisting, standing, or walking. Her symptoms have
become progressively worse with time. She denied any bowel or
bladder difficulties.
Recent workups included MRI study, which showed an L5-S1 disc
herniation, sequestered to the left. Other collateral symptoms
include a tingling paresthesia involving the left foot and
subjective weakness of the left foot.
PAST MEDICAL HISTORY: She had a tubal ligation in 1992.
otherwise been in good health.
She has
REVIEW OF SYSTEMS: Unremarkable.
PHYSICAL EXAMINATION: She was ambulatory with an antalgic gait
and a list to the left. HEAD AND NECK: No deformities, neck is
supple. CHEST: Clear. HEART: Normal sinus rhythm. ABDOMEN: Soft
and benign. EXTREMITIES: Revealed normal muscle tone and bulk.
NEURO: She has weakness with plantar flexion of the left foot and
an absent left ankle jerk. The sensory exam revealed decreased
pinprick sensation over the S1 distribution on the left. Straight
leg raising was positive on the left at about 30 degrees.
IMPRESSION:
1.
Lumbar disc herniation, L5-S1.
2.
Left sciatica.
PLANS: She will undergo a lumbar laminotomy and discectomy.
procedure, risks and complications were discussed with the
patient.
The