History and Physical Examination
HISTORY AND PHYSICAL EXAMINATION
Patient Name: Deanna Martinez
ID No.: 117232
Room No.: 425
Date of Admission: 05/26/2013
Admitting Physician: Sheila Goodman, MD
Admitting Diagnosis: Questionable herniated disk
Chief Complain: Low back pain, right leg pain.
HISTORY OF PRESENT ILLNESS: This 40-year-old Latin female presents with complaints of low back and right leg pain. She said that she hurt her back in a motor vehicle accident three years ago 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 weighed 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 exacerbates her pain. She has to move around to get comfortable when lying down, but she is more comfortable lying down than in any other position. She is still working fulltime, but is not doing the heavy lifting at this time. She has been going to a Chiropractor for the last two months with no pain relief. She has taken Flexeril, Norflex, Tylenol with codeine and Darvocet. All of these have failed to improve her symptoms. She had a CT scan done recently and we are getting those results.
PAST HISTORY: Significant for cesarean section 20 years ago, otherwise negative except as in HPI.
ALLERGIES: Some environmental 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, who is in the military.
SOCIAL HISTORY: Denies x3. No blood transfusion in the past.
PHYSICAL EXAMINATION: This well-developed, well-nourished, thin, pleasant, 40-year-old Latin female is in some distress due to pain.
(Continued)
Patient Name: Deanna Martinez
ID No.:
Patient Name: Deanna Martinez
ID No.: 117232
Room No.: 425
Date of Admission: 05/26/2013
Admitting Physician: Sheila Goodman, MD
Admitting Diagnosis: Questionable herniated disk
Chief Complain: Low back pain, right leg pain.
HISTORY OF PRESENT ILLNESS: This 40-year-old Latin female presents with complaints of low back and right leg pain. She said that she hurt her back in a motor vehicle accident three years ago 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 weighed 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 exacerbates her pain. She has to move around to get comfortable when lying down, but she is more comfortable lying down than in any other position. She is still working fulltime, but is not doing the heavy lifting at this time. She has been going to a Chiropractor for the last two months with no pain relief. She has taken Flexeril, Norflex, Tylenol with codeine and Darvocet. All of these have failed to improve her symptoms. She had a CT scan done recently and we are getting those results.
PAST HISTORY: Significant for cesarean section 20 years ago, otherwise negative except as in HPI.
ALLERGIES: Some environmental 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, who is in the military.
SOCIAL HISTORY: Denies x3. No blood transfusion in the past.
PHYSICAL EXAMINATION: This well-developed, well-nourished, thin, pleasant, 40-year-old Latin female is in some distress due to pain.
(Continued)
Patient Name: Deanna Martinez
ID No.: