Sample Type / Medical Specialty: Orthopedic
Sample Name: Anterior Cervical Discectomy - 2
Description: Anterior cervical discectomy at C5-6 and placement of artificial disk replacement. Right C5-C6 herniated nucleus pulposus.
(Medical Transcription Sample Report)
ADMITTING DIAGNOSIS: Right C5-C6 herniated nucleus pulposus.
PRIMARY OPERATIVE PROCEDURE: Anterior cervical discectomy at C5-6 and placement of artificial disk replacement.
SUMMARY: This is a pleasant, 43-year-old woman, who has been having neck pain and right arm pain for a period of time which has not responded to conservative treatment including ESIs. She underwent another MRI and significant degenerative disease at C5-6 with a central and right-sided herniation was noted. Risks and benefits of the surgery were discussed with her and she wished to proceed with surgery. She was interested in participating in the artificial disk replacement study and was entered into that study. She was randomly picked for the artificial disk and underwent the above named procedure on 08/27/2007. She has done well postoperatively with a sensation of right arm pain and numbness in her fingers. She will have x-rays AP and lateral this morning which will be reviewed and she will be discharged home today if she is doing well. She will follow up with Dr. X in 2 weeks in the clinic as per the study protocol with cervical AP and lateral x-rays with ring prior to the appointment. She will contact our office prior to her appointment if she has problems. Prescriptions were written for Flexeril 10 mg 1 p.o. t.i.d. p.r.n. #50 with 1 refill and Lortab 7.5/500 mg 1 to 2 q.6 h. p.r.n. #60 with 1 refill.
Keywords: orthopedic, herniated nucleus pulposus, anterior cervical discectomy, artificial disk replacement, cervical, discectomy, nucleus,