Sample Name: Anterior Cervical Discectomy & Fusion - Discharge Summary
Description: Anterior cervical discectomy and fusions C4-5, C5-6, C6-7 using Bengal cages and Slimlock plate C4 to C7; intraoperative x-ray. Herniated nucleuses pulposus, C5-6 greater than C6-7, left greater than C4-5 right with left radiculopathy and moderate stenosis C5-6.
(Medical Transcription Sample Report)
1. Herniated nucleuses pulposus, C5-6 greater than C6-7, left greater than C4-5 right with left radiculopathy.
2. Moderate stenosis C5-6.
OPERATION: On 06/25/07, anterior cervical discectomy and fusions C4-5, C5-6, C6-7 using Bengal cages and Slimlock plate C4 to C7; intraoperative x-ray.
This is a 60-year-old white male who was in the office on 05/01/07 because of neck pain with left radiculopathy and "tension headaches." In the last year or so, he has had more and more difficulty and more recently has developed tingling and numbness into the fingers of the left hand greater than right. He has some neck pain at times and has seen Dr. X for an epidural steroid injection, which was very helpful. More recently he saw Dr. Y and went through some physical therapy without much relief.
Cervical MRI scan was obtained and revealed a large right-sided disc herniation at C4-5 with significant midline herniations at C5-6 and a large left HNP at C6-7. In view of the multiple levels of pathology, I was not confident that anything short of surgical intervention would give him significant relief. The procedure and its risk were fully discussed and he decided to proceed with the operation.
By 06/27/07, he was ready to go home. He has been counseled regarding wound care and has received a neck sheet for instruction. He will be seen in two weeks for wound check and for a followup evaluation/x-rays in about six weeks. He has prescriptions for Lortab 7.5 mg and Robaxin 750 mg. He is to call if there are any problems.
Keywords: discharge summary, slimlock, herniated nucleuses pulposus, anterior cervical discectomy, bengal cages, anterior, herniated, cervical, radiculopathy, discectomy,