Hillcrest Medical Case 6
HISTORY AND PHYSICAL EXAMINATION or EMERGENCY DEPARTMENT TREATMENT RECORD
Patient Name: Lydia Cruz
Patient ID: DOB: Age: 40 Sex: F
Hospital Number: 11723
Room No.: 425
Date of Admission/Date of Arrival: 05/26/2012
Admitting/Attending Physician: Tomas Burgos, MD
Admitting Diagnosis: Questionable Herniated disk.
Chief Complaint: Low back pain, right leg pain.
HISTORY OF PRESENT ILLNESS: This 40-year-old black Latin female presents with complaints of low back and right leg pain. She says that she hurt her back in a motor vehicle accident in 2000 and she has had a history of intermittent low back pain since that time. Last December she started a job where she had to lift boxes that weight approximately 40 pounds. Around the first of January this year she began to complain of back pain that gradually went into her right leg. The pain is primarily in the sacroiliac region and radiates into the buttock and lateral lower leg as far as the ankle. She has no numbness. Coughing and sneezing exacerbate her pain. She has to move around to get comfortable when lying down but she is more comfortable lying down then in any other position. She is still working full-time but is not doing the heavy lifting at this time. She has been going to a chiropractor for the last 2 months with no pain relief. She is taking Flexeril, Norflex, Tylenol with Codeine, and Darvocet. All of these have failed to improve her symptoms. She had a CT scan done recently.
PAST HISTORY: A cesarean section in 1990.
ALLERGIES: No known drug allergies.
FAMILY HISTORY: The patient was adopted and does not know her family history. She lives with her husband. She has one son living and well.
SOCIAL HISTORY: Denies x3.
(Continued)
BLOOD TRANSFUSIONS: None.
PHYSICAL EXAMINATION: This well-developed, well-nourished, thin, pleasant, black, 40 year-old female is in no acute distress.
HEENT: The patient wears dentures, otherwise normal.
NECK: Subdual, no JVD, no
Patient Name: Lydia Cruz
Patient ID: DOB: Age: 40 Sex: F
Hospital Number: 11723
Room No.: 425
Date of Admission/Date of Arrival: 05/26/2012
Admitting/Attending Physician: Tomas Burgos, MD
Admitting Diagnosis: Questionable Herniated disk.
Chief Complaint: Low back pain, right leg pain.
HISTORY OF PRESENT ILLNESS: This 40-year-old black Latin female presents with complaints of low back and right leg pain. She says that she hurt her back in a motor vehicle accident in 2000 and she has had a history of intermittent low back pain since that time. Last December she started a job where she had to lift boxes that weight approximately 40 pounds. Around the first of January this year she began to complain of back pain that gradually went into her right leg. The pain is primarily in the sacroiliac region and radiates into the buttock and lateral lower leg as far as the ankle. She has no numbness. Coughing and sneezing exacerbate her pain. She has to move around to get comfortable when lying down but she is more comfortable lying down then in any other position. She is still working full-time but is not doing the heavy lifting at this time. She has been going to a chiropractor for the last 2 months with no pain relief. She is taking Flexeril, Norflex, Tylenol with Codeine, and Darvocet. All of these have failed to improve her symptoms. She had a CT scan done recently.
PAST HISTORY: A cesarean section in 1990.
ALLERGIES: No known drug allergies.
FAMILY HISTORY: The patient was adopted and does not know her family history. She lives with her husband. She has one son living and well.
SOCIAL HISTORY: Denies x3.
(Continued)
BLOOD TRANSFUSIONS: None.
PHYSICAL EXAMINATION: This well-developed, well-nourished, thin, pleasant, black, 40 year-old female is in no acute distress.
HEENT: The patient wears dentures, otherwise normal.
NECK: Subdual, no JVD, no