tokens: 018636330 DH 5425710 123524 0144918 6/2/2005 12:00:00 AM Discharge Summary Signed DIS Report Status : Signed DISCHARGE SUMMARY NAME : KOTE , OA UNIT NUMBER : 509-22-30 ADMISSION DATE : 06/02/2005 DISCHARGE DATE : 06/05/2005 PRINCIPAL DIAGNOSIS : C5-6 disc herniation with cord compression and myelopathy . PRINCIPAL PROCEDURE : Microscopic anterior cervical diskectomy at C5-6 and fusion . HISTORY OF PRESENT ILLNESS : The patient is a 63-year-old female with a three-year history of bilateral hand numbness and occasional weakness . Within the past year , these symptoms have progressively gotten worse , to encompass also her feet . She had a workup by her neurologist and an MRI revealed a C5-6 disc herniation with cord compression and a T2 signal change at that level . PAST MEDICAL HISTORY : Significant for hypertension , hyperlipidemia . MEDICATIONS ON ADMISSION : Lipitor , Flexeril , hydrochlorothiazide and Norvasc . ALLERGIES : She has no known drug allergy . SOCIAL HISTORY : She smokes one pack per day x45 years . She occasionally drinks alcohol . PHYSICAL EXAMINATION : She had 5/5 strength in bilateral upper and lower extremities . She had a Hoffman &apos;s sign greater on the right than the left and she had 10 beats of clonus in the right foot and 3-5 beats in the left foot . She had hyperreflexia in both the bilateral upper and lower extremities . HOSPITAL COURSE : The patient tolerated a C5-6 ACDF by Dr. Miezetri Gach quite well . She had a postoperative CT scan that revealed partial decompression of the spinal canal and good placement of her hardware . Immediately postop , her exam only improved slightly in her hyperreflexia . She was ambulating by postoperative day number two . She tolerated a regular diet . Her pain was under good control with PO pain medications and she was deemed suitable for discharge . DISCHARGE ORDERS : The patient was asked to call Dr. Miezetri Gach &apos;s office for a follow-up appointment and wound check . She is asked to call with any fevers , chills , increasing weakness or numbness or any bowel and bladder disruption . DISCHARGE MEDICATIONS : She was discharged on the following medications . 1. Colace , 100 mg PO bid . 2. Zantac , 150 mg PO bid . 3. Percocet , 5/325 , 1-2 tabs PO q4-6h prn pain . 4. Lipitor , 10 mg PO daily . 5. Hydrochlorothiazide , 25 mg PO daily . 6. Norvasc , 5 mg PO daily . LALIND KOTE , M.D. DICTATING FOR : Electronically Signed MIEZETRI NIMIRY POP , M.D. 08/01/2005 18:50 _____________________________ MIEZETRI NIMIRY POP , M.D. TR : qg DD : 07/30/2005 TD : 07/31/2005 9:43 A 123524 cc : MIEZETRI NIMIRY POP , M.D.