Detailed Treatment Process
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Discharge Summary Department: Orthopedics Gender: Male Age: 61 years Admission Date: August 31 Discharge Date: September 3 Admission Diagnosis: 1. M48.0 (lumbar) spinal stenosis; 2. I10.x00 essential hypertension Discharge Diagnosis: 1. M48.0 (lumbar) spinal stenosis; 2. I10.x00 essential hypertension 【Admission Status】 1. Chief Complaint: Low back pain with right lower limb soreness, numbness, and weakness for over one year 2. History of Present Illness: Over one year ago, following a fall, the patient developed low back pain accompanied by soreness, numbness, and weakness in the right lower limb. Symptoms eased with rest in the supine position but worsened with standing and walking. Conservative treatment and rest brought no significant improvement, seriously affecting daily life. In the past year, symptoms gradually worsened with intermittent claudication. An MRI performed at another hospital showed lumbar degenerative changes, Schmorl’s nodes at the superior and inferior margins of some vertebral bodies, bulging of the L3/4–L4/5 intervertebral discs with narrowing of the disc spaces. He presented to our hospital on August 31 and was admitted with a diagnosis of “L3/4 and L4/5 disc bulging with spinal stenosis.” 3. Physical Examination: Lumbar physiological curvature preserved, mild limitation of lumbar flexion and extension, tenderness at L3/4–L4/5 (+), reduced superficial sensation in the L5 dermatome of the right lower limb, essentially normal muscle strength for dorsiflexion of the feet and toes and plantar flexion bilaterally, palpable dorsalis pedis pulses, right straight-leg raise limited to 40 degrees, absent ankle reflexes bilaterally, normal knee reflexes, negative pathological signs. 4. Ancillary Investigations: MRI (outside hospital, May 30): lumbar degenerative changes, Schmorl’s nodes at the superior and inferior margins of some vertebral bodies, bulging of the L3/4–L4/5 intervertebral discs with narrowing of the disc spaces. 【Treatment Course】 1. Main Laboratory Results: White blood cell count: 5.4 × 10⁹/L, neutrophil count: 3.17 × 10⁹/L, lymphocyte count: 1.76 × 10⁹/L, neutrophil percentage: 58.94%, lymphocyte percentage: 32.74%, hemoglobin: 142 g/L, hematocrit: 43.00%, platelet count: 146 × 10⁹/L, glucose: 5.29 mmol/L, urea: 5.5 mmol/L, creatinine: 81 μmol/L, uric acid: 325 μmol/L, total protein: 66 g/L, albumin: 43 g/L, alanine aminotransferase: 9.40 U/L, aspartate aminotransferase: 19.10 U/L, total cholesterol: 3.94 mmol/L, triglycerides: 1.50 mmol/L, high-density lipoprotein cholesterol: 0.79 mmol/L, low-density lipoprotein cholesterol: 2.27 mmol/L, international normalized ratio: 1.02, prothrombin activity: 97.00%, activated partial thromboplastin time: 33.30 s, fibrinogen: 3.92 g/L, thrombin time: 13.8 s, D-dimer: 2.03 μg/ml. 2. Special Investigations and Important Consultations: Head MRI: Multiple lacunar foci in the periventricular regions and subcortical white matter of the frontal and parietal lobes. Submucosal cyst in the right maxillary sinus, hypertrophy of the right inferior turbinate, deviated nasal septum. Chest CT: Bullae in the upper lobes of both lungs. Spotty lesion in the right upper lobe. Interstitial changes with fibrous strands in the lower lobes of both lungs. Calcification of the aorta and coronary arteries. Cystic lesion in the liver, gallstones. Nodular thickening of both adrenal glands, follow-up recommended. Electrocardiogram: Sinus bradycardia. 3. Course and Treatment: After admission, the patient completed the necessary investigations. With no surgical contraindications identified, he underwent L3/4–L4/5 lumbar disc nerve decompression under local anesthesia on September 1. The procedure was uneventful, followed by symptomatic supportive care. 4. Treatment Outcome: Improved 【Discharge Status】 The patient was in good general condition with marked improvement in symptoms. The surgical wound was dry with no obvious redness, swelling, or exudation. Distal limb movement and circulation were normal. 【Discharge Instructions】 1. Medication Advice After Discharge: None specified 2. Follow-up: Keep the wound clean and dry. Return to the outpatient clinic in one month for review. Seek immediate medical attention if any special discomfort occurs. Date: September 3