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Brendan Kearney

Case Study

11-1-2015

Case Study
Patient: Patient A was the first patient I saw last week when I went through
office rotations. Patient A is a 73 year old female, returning to doctor Santos
office to make a decision on whether or not to have surgery. She has a long
history of chronic back pain. In the last few months, she has not been able
to walk due to the severity of new, more intense pain. She has been
wheelchair-bound for the last two weeks, and is complaining of muscle
weakness in her lower extremities.
Pathophysiology: A disc herniation occurs when the fibrous ring around the
intervertebral disc tears and allows the internal soft cushion between the
vertebrae to bulge out. This bulging can cause inflammation and irritation of
the surrounding nerves, which can affect the extremities, causing weakness
or numbness in the arms or legs.
Signs/Symptoms: Patient A complained of chronic lower back pain during
her first visit. She was instructed to monitor her condition for numbness,
weakness, or an increase in pain. On her second visit, which I attended, she
arrived in a wheelchair. Since her first visit, her condition had greatly
deteriorated, and she said her pain had doubled and her legs had become
weak. Diagnosis: Dr. Santos ordered an MRI to diagnose her condition. The
MRI showed a bulge of tissue protruding between vertebrae T12 and L1, a
classic indication of a herniated disc. Dr. Santos could tell that her condition

Brendan Kearney

Case Study

11-1-2015

was worsening because her symptoms were becoming more severe over
time.
Medical/Surgical Treatment: After diagnosing Patient A with a herniated
disc, Dr. Santos recommended she have a surgical procedure called a
Discectomy. In this procedure, the disc between the vertebrae is removed.
Because the entire disc is being removed, he also recommended that Patient
A have a spinal fusion. In this procedure, both vertebrae will be joined
together with a metal plate which keeps the vertebrae from moving.
Prognosis: Patient A will stay in the recovery room for three days after the
surgery. If everything goes according to plan and there are no signs of
infection she will be released. After she is released from the hospital, due to
the strength of the fusion, she will have no restrictions in physical activity. If
a fusion was not preformed she would have to be very cautious to not
damage the vertebrae.
Phychological/Social: After the procedure, Patient As lifestyle should
greatly improve. She should be able to walk and live without physical
limitations of her back. Without the inflammation putting pressure on the
nerves, the weakness in her legs should go away.

Work Cited

Brendan Kearney

Case Study

11-1-2015

Brendan Kearney personal notes. Dr. Eric Santos Office. October 29, 2015.

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