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Ms. Rodriguez Case Summary

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Ms. Rodriguez is a 50-year-old female with previous histories of lumbar spinal surgeries in 2004 and 2012 and a cervical fusion surgery in 2013. She previously underwent a fusion and reconstruction extending from L2-S1. She had evidence of junctional disk compromise facet arthropathy L1-2, and presented with mechanical and radicular symptoms. Despite medical and surgical management, physical therapy, and injection modalities, she had persistence and progression of her back, gluteal, left inguinal, and left leg pain with worsening of her gait and posture. (004)

On 3/9/2015, Ms. Rodriguez was admitted at Sunrise Medical Center for elective surgery to address these concerns.

The operative report by Jaswinder Grover, MD documented that the …show more content…
Resa Vaghefi- Hosseini at 18:35 document that Ms. Rodriguez complained of post-operative pain but had no neurological deficits at the time of the exam. She was admitted for overnight observation and blood pressure and pain control. (005) The nurses' notes at 23:30 reported that Ms. Rodriguez was transferred from the PACU to room 3114. Upon discharge from the PACU, she had a Glasgow coma scale of 15 and was receiving oxygen support via nasal cannula at 3 liters per minute (066, 074)

In her deposition on 2/27/2017 at 10:15, Lottie Barnes, RN agreed that Ms. Rodriguez had " no real complaints of pain, numbness, or tingling in the lower extremity, no numbness or paresthesia" when she was transferred out of the PACU to the regular floor. This statement was consistent with her nurse's notes on 3/9/3015 at 23:30. (145)

A neuro check documented on 3/10/2015 at 00:00 reported that Ms. Rodriguez had a pain scale of 8, and a GCS of 13. She had eye opening to pain and was able to follow commands but complained of numbness and weakness of both legs …show more content…
Rodriguez complained of weakness, had significant anxiety with movement, and was fearful of pain. On her first post-operative day, she was noted to be awake but lethargic, had no movement of the right lower extremity, some minimal movement of the toes, hamstring/quadriceps of the left lower extremity, and hypersensitivity of the right lower extremity. A stat MRI of the thoracic and lumbar spine was ordered. Her wound dressing and JP drain were both intact. Her glucose level (214) and white blood cell count (17) were likewise elevated while her calcium level was low. (8.3). Ativan was prescribed for her anxiety while Decadron was

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