Physiatry Consultation Medical Transcription Sample Reports


DATE OF CONSULTATION:  MM/DD/YYYY

REFERRING PHYSICIAN:  John Doe, MD  

REASON FOR CONSULTATION:  Herpes encephalitis.

HISTORY OF PRESENT ILLNESS:  The patient is a (XX)-year-old right-handed woman with a history of hypothyroidism and depression who was admitted with headaches, fevers and mental status changes for a few days prior to admission. A CT scan of the brain reportedly revealed an early left MCA infarct. The patient had a decline in her status. She was intubated and transferred to the intensive care unit. She was posturing. MRI of the brain and lumbar puncture were consistent with encephalitis. MRA was negative.

Echocardiogram was unremarkable. EEG demonstrated slowing but no seizure activity. Test did reveal that she was positive for herpes simplex virus per PCR. She was started on acyclovir. West Nile virus testing was negative. The patient was extubated. She had stridor. Laryngoscopy revealed bilateral vocal cord paralysis. Intravenous steroids were started. She was reintubated. She underwent a tracheostomy yesterday. A PEG tube is pending. The next day, the patient was noted to have questionable right upper extremity focal seizure activity. She was placed on valproic acid. A followup EEG was obtained. No seizure activity was noted. There was generalized slowing.

Overall, there has not been that much improvement in the patient's cognitive status. She does not appear to be in any discomfort. She is n.p.o.

PAST MEDICAL HISTORY:  Depression. She is followed by a psychiatrist and a counselor. She had radiation treatment to her thyroid and is now on thyroid supplementation. She had tonsillectomy as a child.

ALLERGIES:  NONE.

MEDICATIONS:  Valproic acid 500 mg IV piggyback q.12 h., multivitamin 1 per tube daily, Synthroid 125 mcg IV piggyback daily, acyclovir 500 mg IV piggyback q.8 h. (day 12), cefepime 2 grams IV piggyback q.8 h. (day 11), heparin 5000 units subcutaneously q.12 h., Protonix 40 mg IV push daily, Lactinex 1 package per tube q.i.d., aspirin 325 mg per tube daily, and p.r.n. medications include morphine, Versed, Tylenol and Tylenol No. 3. She has not been receiving any Versed or morphine recently.

PRE-ADMISSION MEDICATIONS:  Cymbalta 20 mg daily and Synthroid 100 mcg daily.

DIET:  The patient is n.p.o. The patient is receiving IV fluids of normal saline at 100 mL/hour. She is on Jevity 1.2 at 45 mL/hour with 60 mL water flush b.i.d. after she receives 1 package of Beneprotein.

FUNCTIONAL STATUS:  The patient has a Foley catheter. She is dependent for her care at this time. She was independent with her care prior to her hospitalization.

SOCIAL HISTORY: The patient is married. She has 3 sons. She works full time. They live in a tri-level home with 4 steps in from the garage and 5 steps in from the front door. There are a total of 18 steps up to her bedroom. The patient does not smoke. She is a social drinker.

FAMILY HISTORY:  Mother died in her 80s from myocardial infarction. Her father is alive in his 90s.

REVIEW OF SYSTEMS:  Per the HPI and PMH. Hypothyroidism, urinary tract infections.

PHYSICAL EXAMINATION:
VITAL SIGNS:  Temperature 101.6, T-max 103.4, pulse 110, respirations 22, and blood pressure 162/82. Oxygen saturation is 99% on 40% O2 per the ventilator. Height 5 feet 4 inches, weight 114 pounds.
GENERAL APPEARANCE:  Well-developed, well-nourished woman who does not appear to be in any distress or discomfort.
HEENT:  NC/AT.
NECK:  Without bruits. Tracheostomy site was clean, dry and intact.
LUNGS:  Clear.
HEART:  Tachycardia with a normal rhythm and without murmur.
ABDOMEN:  Bowel sounds diminished, soft and nondistended.
EXTREMITIES:  No clubbing, cyanosis or edema. No calf erythema or warmth. Peripheral pulses were strong and symmetrical. Passive range of motion was within functional limits throughout; although, it was somewhat difficult to range her ankles into the neutral position.
SKIN:  Intact.
NEUROLOGICAL:  Mental Status:  The patient was arousable. There was no attempt to voice. She did not follow instructions. She did not track. She did blink to threat. Cranial Nerves:  Extraocular movements cannot be tested. Visual fields could not be tested. Facies were symmetric. Hearing could not be tested. Shoulder shrug could not be tested. Tongue protrusion could not be tested. Motor:  The right upper extremity had involuntary rhythmic movements. Tone was slightly increased in all 4 extremities. Generalized atrophy was noted. She did not move her extremities to command. She did have minimal voluntary movement in all 4 extremities, left side greater than right. Muscle stretch reflex is 3+ throughout the bilateral upper and lower extremities with upgoing toes bilaterally. Hoffmann sign was negative bilaterally. Coordination:  Not applicable. Sensory:  The patient did respond to painful stimuli. Gait:  Not applicable.

LABORATORY DATA:  Hemoglobin 9.2, white blood cell count 12,600 and platelet count 632,000. ESR last month was 22. Lupus anticoagulant was negative. Protein C was slightly low at 46. Protein S was normal at 72. Anticardiolipin antibody tests were negative. Factor V Leiden mutation was negative. Sodium 134, potassium 3.9, chloride 99, bicarbonate 26, BUN 18, creatinine 0.8, glucose 98, and calcium 8.2. Albumin 2.4, total protein 6.4. Homocysteine was normal at 6. RPR was nonreactive. HIV was negative. Cholesterol 101, HDL 36, LDL 56 and triglycerides 39. Free T4 was 1.06, T4 was 7.6 and T3 was 0.7. These were all normal. TSH was elevated at 8.27.

ASSESSMENT:
  1. Herpes encephalitis.
  2. Encephalopathy and incomplete tetraplegia.
  3. Questionable right upper extremity focal seizures.
  4. Respiratory failure.
  5. Bilateral vocal cord paralysis.
  6. Fevers.
  7. Dyslipidemia, decreased high-density lipoprotein.
  8. Tracheostomy. Percutaneous endoscopic gastrostomy tube placement is pending.
  9. Hypothyroidism.
  10. Anemia.
  11. Leukocytosis.
  12. Thrombocytosis.
  13. Depression.
  14. Constipation.
RECOMMENDATIONS:
  1. Physical, occupational and speech therapies should continue. The patient is not appropriate for acute rehabilitation at this time. I agree with long-term acute care hospital placement until her function improves and she has an increased ability to participate.
  2. A KUB will be obtained and a bowel program will be initiated.
  3. The patient's valproic acid level should be monitored as well as liver function tests.
  4. Oral hygiene should be performed every shift.
  5. A prealbumin level will be obtained and then obtained weekly.
  6. Family conference should be held to discuss postacute care options, etc. The assessment and recommendations were discussed with the patient's brother.
Thank you for allowing us to participate in the care of this pleasant patient.



DATE OF CONSULTATION:  MM/DD/YYYY

REFERRING PHYSICIAN:  John Doe, MD 

REASON FOR CONSULTATION:  Impaired mobility and self-care.

HISTORY OF PRESENT ILLNESS:  The patient is a (XX)-year-old male admitted initially for complaints of fever and chills during hemodialysis and was also found to be hypotensive. On admission, he was diagnosed with right leg cellulitis and podiatry service and ID service were consulted. He was started on IV antibiotics and hemodialysis tunneled catheter was also removed and sent for culture.

Renal services were further consulted for management of renal failure. Cardiology service was also involved and a workup with a 2-D echocardiogram revealed an ejection fraction of 35%. Subsequently, secondary to infection, the patient further underwent a transmetatarsal amputation of the right foot with rotation flap and right ankle Achilles tendon lengthening with a delayed primary closure of the right foot. Postoperatively, he was placed on nonweightbearing on the right lower extremity.

Physical therapy and occupational therapy were initiated. He was also noted to have loose bowel movements and workup for C. difficile is still pending. Physical medicine rehabilitation services have now been consulted for appropriateness regarding short stay in acute rehab.

REVIEW OF SYSTEMS:  Denies any chest pain, shortness of breath or abdominal pain. Right leg and foot pain is about 4/5, generalized weakness. Otherwise, 10 system review was negative. Minimal left eye blurred vision.

PAST MEDICAL HISTORY:  Coronary artery disease, status post CABG; diabetes type 2; hypertension; chronic renal failure, on hemodialysis; congestive heart failure, ejection fraction 35%; hypercholesterolemia; peripheral vascular disease with occluded right carotid artery and ischemic legs; right eye blindness and blurred vision in the left eye.

ALLERGIES:  NO KNOWN ALLERGIES.

MEDICATIONS:  Vitamin B and C, Colace, aspirin, Humalog, Renagel, midodrine, vitamin E and C, Procrit, Protonix, Zosyn, daptomycin, levofloxacin, and IV Flagyl.

SOCIAL HISTORY:  The patient lives with his wife in a 2-level home with 10 stairs. Denies any alcohol or tobacco use.

FUNCTIONAL HISTORY:  Prior to admission, the patient needed assistance with walking. Currently, bed mobility is modified independent and ambulation was not tested secondary to refusal. Occupational therapy has not been initiated. 

PHYSICAL EXAMINATION:  
VITAL SIGNS:  Stable.
GENERAL:  The patient is alert and oriented x3. Cognition seems intact. 
HEENT:  Pupils are equal, round, reactive to light and accommodation.
LUNGS:  Clear to auscultation.
CARDIOVASCULAR:  Regular rate and rhythm. Normal heart sounds.
ABDOMEN:  Soft, nontender with good bowel sounds.
EXTREMITIES:  Reveal no lower extremity edema. Motor strength in the upper extremity is 4/5 throughout in all muscle groups, left lower extremity is 4/5, right lower extremity, leg, and foot not tested secondary to surgical site. Proximal muscles are 3+/5. Sensation is normal in the upper extremities and impaired to light touch in the lower extremities. Tone is normal. Coordination is intact. Sitting balance is good. Gait was not tested.

DIAGNOSES:
  1. Deconditioning, right foot cellulitis, status post right foot transmetatarsal amputation.
  2. Peripheral vascular disease. 
  3. Chronic renal failure, on hemodialysis.
  4. Diabetes.
  5. Coronary artery disease.
  6. Congestive heart failure.
RECOMMENDATION:  The patient is deconditioned but at a higher functional level of modified independence for bed mobility, and because of his comorbidities, his endurance is poor. Also, he is on different IV antibiotics, duration most likely for a few weeks. Hence, acute rehab will not be appropriate, but extended care facility with low intensity therapies and continuation of antibiotics would be a better option.

Recommend extended care facility at this time. This plan of care was discussed with the patient. 

Thank you for the consult. If you have any questions, please do not hesitate to call me.






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