699905656 SC
06100044
921737
1/17/1993 12:00:00 AM
Discharge Summary
Signed
DIS
Admission Date :
01/17/1993
Report Status :
Signed
Discharge Date :
01/21/1993
DISCHARGE DIAGNOSIS :
1. RIGHT SIDED SCIATICA PROCEDURE :
Right laminectomy and discectomy by Dr. Small , Neurosurgery .
HISTORY OF PRESENT ILLNESS :
The patient is a 42 year old gentleman who suffered lower back pain during an accident at work in 1990 .
This gradually increased until June 1992 where he had recurrent severe right sided sciatica .
In September 1992 CT myelogram showed a lateral L-1 S-1 disc bulge and small L-4-4 bulge .
He has had no change in pain in the last few months .
PAST MEDICAL HISTORY :
Negative .
ALLERGIES :
None .
MEDICATIONS :
None .
PHYSICAL EXAMINATION :
He was found to be healthy .
His examination was completely unremarkable .
He had 5 out of 5 strength diffusely , normal deep tendon reflexes and normal sensation .
HOSPITAL COURSE :
He was admitted , taken to the operating room where he underwent L5-S1 right hemilaminectomy and discectomy .
He tolerated the procedure well , was taken to the floor in stable condition .
Over the next three days he increased his activity gradually , was able to do stairs with Physical Therapy and had pain which could be controlled with oral analgesics .
DISPOSITION :
MEDICATIONS :
He is discharged on Percocet , Colace and Motrin .
Dictated By :
NASA R. SMALL , M.D. IX97
Attending :
VIENNIEZUTACHANT WAVE , M.D. NN08 QM838/6096
Batch :
8704
Index No. AFUFB928WZ
D :
01/20/93
T :
01/22/93