018636330 DH
5425710
123524
0144918
6/2/2005 12:00:00 AM
Discharge Summary
Signed
DIS
Report Status :
Signed
DISCHARGE SUMMARY
NAME :
KOTE , OA
UNIT NUMBER :
509-22-30
ADMISSION DATE :
06/02/2005
DISCHARGE DATE :
06/05/2005
PRINCIPAL DIAGNOSIS :
C5-6 disc herniation with cord compression and myelopathy .
PRINCIPAL PROCEDURE :
Microscopic anterior cervical diskectomy at C5-6 and fusion .
HISTORY OF PRESENT ILLNESS :
The patient is a 63-year-old female with a three-year history of bilateral hand numbness and occasional weakness .
Within the past year , these symptoms have progressively gotten worse , to encompass also her feet .
She had a workup by her neurologist and an MRI revealed a C5-6 disc herniation with cord compression and a T2 signal change at that level .
PAST MEDICAL HISTORY :
Significant for hypertension , hyperlipidemia .
MEDICATIONS ON ADMISSION :
Lipitor , Flexeril , hydrochlorothiazide and Norvasc .
ALLERGIES :
She has no known drug allergy .
SOCIAL HISTORY :
She smokes one pack per day x45 years .
She occasionally drinks alcohol .
PHYSICAL EXAMINATION :
She had 5/5 strength in bilateral upper and lower extremities .
She had a Hoffman 's sign greater on the right than the left and she had 10 beats of clonus in the right foot and 3-5 beats in the left foot .
She had hyperreflexia in both the bilateral upper and lower extremities .
HOSPITAL COURSE :
The patient tolerated a C5-6 ACDF by Dr. Miezetri Gach quite well .
She had a postoperative CT scan that revealed partial decompression of the spinal canal and good placement of her hardware .
Immediately postop , her exam only improved slightly in her hyperreflexia .
She was ambulating by postoperative day number two .
She tolerated a regular diet .
Her pain was under good control with PO pain medications and she was deemed suitable for discharge .
DISCHARGE ORDERS :
The patient was asked to call Dr. Miezetri Gach 's office for a follow-up appointment and wound check .
She is asked to call with any fevers , chills , increasing weakness or numbness or any bowel and bladder disruption .
DISCHARGE MEDICATIONS :
She was discharged on the following medications .
1. Colace , 100 mg PO bid .
2. Zantac , 150 mg PO bid .
3. Percocet , 5/325 , 1-2 tabs PO q4-6h prn pain .
4. Lipitor , 10 mg PO daily .
5. Hydrochlorothiazide , 25 mg PO daily .
6. Norvasc , 5 mg PO daily .
LALIND KOTE , M.D.
DICTATING FOR :
Electronically Signed MIEZETRI NIMIRY POP , M.D. 08/01/2005 18:50
_____________________________ MIEZETRI NIMIRY POP , M.D.
TR :
qg
DD :
07/30/2005
TD :
07/31/2005 9:43 A 123524
cc :
MIEZETRI NIMIRY POP , M.D.