HISTORY AND PHYSICAL EXAMINATION or EMERGENCY DIVISION TREATMENT RECORD
Patient Term: Lydia Cruz
Patient ID: DOB: Age group: 40Sex: N
Hospital Amount: 11723
Space No .: 425
Date of Admission/Date of Arrival: 05/26/2012
Admitting/Attending Medical doctor: Tomas Burgos, MD
Acknowledging Diagnosis: Sketchy Herniated drive.
Chief Problem: Low back pain, right leg soreness.
HISTORY OF PRESENT ILLNESS: This 40-year-old dark-colored Latin female presents with complaints of low as well as right lower-leg pain. States that the lady hurt her back in a car accident in 2000 and she has a new history of irregular low back pain ever since then. Last December she started a job wherever she was required to lift containers that weight around 40 pounds. Around the first of January this year she started to complain of back pain that gradually went into her right lower-leg. The discomfort is primarily in the sacroiliac region and radiates in to the buttock and lateral lower leg as far as the ankle. This wounderful woman has no pins and needles. Coughing and sneezing exacerbate her discomfort. She has to move to receive comfortable when lying down although she is more comfortable lying down in that case in any additional position. She actually is still operating full-time although not doing the heavy raising at this time. She gets been going to a chiropractor for the last 2 months with no pain relief. She actually is taking Flexeril, Norflex, Tylenol with Codeine, and Darvocet. All of these include failed to increase her symptoms. She a new CT check done recently.
PAST RECORD: A cesarean section in 1990.
ALLERGIC REACTIONS: No well-known drug allergy symptoms.
FAMILY HISTORY: The patient was used and does not find out her family history. She lives with her husband. This lady has one child living and well.
INTERPERSONAL HISTORY: Refuses x3.
BLOOD TRANSFUSIONS: None.
PHYSICAL EXAMINATION: This kind of well-developed, well-nourished, thin, enjoyable, black, forty year-old female is in simply no acute distress.
HEENT: The person wears denture, otherwise usual.
NECK: Subdual, no JVD, no ...