Rehabilitation Discharge Summary Medical Transcription Sample For Medical Transcriptionists


DATE OF ADMISSION:  MM/DD/YYYY

DATE OF DISCHARGE:  MM/DD/YYYY

ADMISSION DIAGNOSIS:  Left below-knee amputation.

DISCHARGE DIAGNOSIS:  Left below-knee amputation.

HISTORY OF PRESENT ILLNESS:  The patient is an (XX)-year-old gentleman with a history of peripheral arterial disease and lower extremity bypass surgeries who was admitted with gangrene of left foot.  The patient underwent left below-knee amputation by Dr. Doe.  The patient was seen postoperatively by Cardiology.  The patient was medically stable.  The patient was requiring assistance and was transferred to rehabilitation.  Left below-knee amputation was performed on MM/DD/YYYY.

PAST MEDICAL HISTORY:  As per HPI, hyperlipidemia and hypertension.

PAST SURGICAL HISTORY:  As per HPI.

SOCIAL HISTORY:  Lives with wife.

FAMILY HISTORY:  Noncontributory.

PHYSICAL EXAMINATION:  At the time of admission, the patient was afebrile.  Vital signs are stable.  Temperature 97.7.  Blood pressure 135/62.  Oral mucosa was moist.  Sclerae anicteric.  Lungs:  Bilaterally clear to auscultation.  Heart:  Regular.  Abdomen:  Scaphoid. Right foot intact.  Left below-knee amputation with staples intact.  Minimal erythema.  Minimal edema.

HOSPITAL COURSE:  The patient was medically stable.  Dr. Doe did come to see the patient.  We did not utilize any compression due to the significant ischemia, which was noted to the stump.  The patient was placed on Avelox.  Bowels moved on a regular basis.  The patient actually did quite well with rehabilitation.  There were some safety concerns.  The patient had repeat of the liver function profile, which was stable.  Appetite did improve during the rehabilitation stay.  Albumin was 2.8.  Hemoglobin was 10.2.  The patient was seen by Nutrition.  The patient was supervision with all ADLs.  Family training was instituted.  Good range of motion was noted to the left knee.  No dehiscence was found.  The patient was discharged on MM/DD/YYYY with wife.

MEDICATIONS:  Avelox 400 mg daily, aspirin one tablet daily, Roxicodone 5-10 mg every 6 hours as needed for pain, Cardizem 60 mg 3 times a day, Nitro-Dur patch daily and Lanoxin 0.25 mg daily.

The patient was to have home health therapy.  The patient was to follow up with Dr. Doe on Thursday or Tuesday.  The patient was to have dry dressings with home health, wrapping with Kling and stockinette, no compression.  The patient was prescribed front-wheel walker, 3-in-1 commode, shower chair and ADL kit.  The patient was prescribed home health nursing, physical therapy, occupational therapy and aide.  The patient was also given a wheelchair.  The patient was afebrile.  Vital signs were stable.  All instructions were given.


-------------------------------
 
DATE OF ADMISSION:  MM/DD/YYYY

DATE OF DISCHARGE:  MM/DD/YYYY
 
DISCHARGE DIAGNOSES:
1.  Traumatic brain injury.
2.  Spasticity.
3.  Bipolar disorder.
4.  Reflex sympathetic dystrophy involving the left upper extremity.
5.  Kluver-Bucy syndrome.
6.  Panic attacks.
7.  Neurogenic bowel and bladder, resolved.
 
HISTORY OF PRESENT ILLNESS:  The patient is a (XX)-year-old who was involved in a MVC on MM/DD/YYYY, with prolonged extrication.  The patient was taken to (XX) Hospital and was found to have multiple shear injuries, small subarachnoid bleed, intracranial hemorrhage, C7 transverse process fractures and pneumothorax.  This hospital course was complicated by mechanical ventilation, with difficult wean.  A tracheostomy and PEG tube were placed on MM/DD/YYYY.  He also received multiple IV antibiotics for ventilator-acquired pneumonia.  BAL was positive for Stenotrophomonas, and the patient was transferred to (XX) on vancomycin, cefepime, nafcillin and Bactrim.  The patient also had blood cultures positive for coag-negative Staphylococcus and Enterococcus faecalis.  He also had autonomic instability.
 
REHABILITATION COURSE:
1.  Rehabilitation:  The patient was seen and evaluated by physical therapy, occupational therapy, speech therapy, recreational therapy, nutrition and psychology.  On admission, the patient was dependent for all self-care, required maximal assistance for grooming, incontinent of bowel and bladder and was dependent for all communication.  Upon discharge, he was able to transfer with standby to contact guard assistance.  He was able to ambulate up to 40 feet with a single point cane with minimal to moderate assistance.  He was able to go up and down one flight of stairs with contact guard assistance, occasionally needing minimal assistance.  He required supervision for bowel and bladder control.  In speech therapy, he required standby to minimal prompts to respond to activities.  He was able to name 5 to 10 items for categories.  He was able to also participate in group therapies without difficulty, involving instructions.
2.  Psychiatry:  When the patient became more verbal and animated, he displayed hyperorality and hypersexuality, which were similar to symptoms in Kluver-Bucy syndrome.  He was empirically started on Tegretol with improvement of his symptoms and Tegretol was continued on discharge.  The patient also had a history of panic attacks in the past.  Clonazepam was started with improvement in him.  The patient also has a history of bipolar disorder.  Prior to this accident, he was on Zyprexa 20 mg secondary to sedation and weight gain.  The patient discontinued his medications.  Prior to discharge, he was started on Depakote 500 mg b.i.d.
3.  Pain:  The patient with spasticity involving his left upper extremity and also reflex sympathetic dystrophy.  He received two stellate ganglion blocks by Dr. Doe with much improvement in his pain.  He had been on Neurontin with minimal relief and this was discontinued prior to discharge.  Most of his pain was involving the wrist and hand.
4.  Spasticity:  Botox injections were performed to the left upper extremity, to the left biceps, brachialis, brachioradialis and FDS.  He was also able to tolerate serial casting for a short amount of time, but this was stopped secondary to his pain he was experiencing from the RSD.  He is now able to tolerate an air cast to his left upper extremity for prolonged periods of time.  He also received a left tibial nerve block with Marcaine with good results.  He is now able to tolerate a bivalved elbow cast with an inflatable handcuff.
5.  Neurogenic bowel and bladder:  Upon transfer, the patient had elevated postvoid residuals.  He was on Flomax and Urecholine and his PSA was elevated at 5.6.  He was seen by Dr. Doe.  The patient’s cognition improved, he was continent of both bowel and bladder.  We discontinued the Flomax on MM/DD/YYYY and followup PVRs were low.  The patient is to follow up with Dr. Doe on MM/DD/YYYY.  Bowels:  The patient had difficulty with constipation earlier in the hospital course, requiring manual disimpaction.  The patient is now having regular bowel movements on senna one tablet in the morning.
6.  Fluid, Electrolytes, and Nutrition:  Upon transfer, the patient was on tube feeds.  Prior to discharge, he was tolerating mechanical soft diet, stage IV liquids and the PEG was pulled on MM/DD/YYYY, without complications.
7.  Sleep:  Early in his hospital course, he had difficulty falling and staying asleep.  Trazodone was increased to 250 mg at bedtime and he experienced nightmares.  This was discontinued and he was switched to Ambien with good results.
 
DISCHARGE MEDICATIONS:
1.  Baclofen 5 mg p.o. daily x3 days.
2.  Senna-S one tablet q.a.m.
3.  Clarinex 5 mg daily.
4.  Ambien 2.5 mg at bedtime.
5.  Tegretol 20 mg p.o. b.i.d.
6.  Clonazepam 0.25 mg b.i.d. and at bedtime.
7.  Depakote 500 mg p.o. b.i.d.
 
ALLERGIES:  No known drug allergies.
 
PROCEDURES:
1.  Botox injection to left elbow flexors.
2.  Stellate ganglion block x2.
3.  Tibial nerve block.
 
PHYSICAL EXAMINATION ON DISCHARGE:  VITAL SIGNS:  Temperature is 98.4, heart rate of 98, BP of 122/84, respirations of 17.  GENERAL:  Well-nourished, well-developed male, sitting in his wheelchair, in no acute distress, pleasant.  HEENT:  Face is symmetric.  Pupils are equal, round and reactive to light.  Extraocular muscles are intact.  Mucous membranes are moist.  No oral thrush.  Tracheostomy site is well healed.  LUNGS:  Clear to auscultation bilaterally.  No rales or wheezes.  CARDIOVASCULAR:  Regular rate and rhythm.  No murmurs.  ABDOMEN:  Previous PEG site is healing well, with good granulation tissue.  No drainage, normoactive bowel sounds throughout, soft, nontender, nondistended.  EXTREMITIES:  Without edema.  Left upper extremity is held in a flexor synergy pattern and left elbow lacks 46 degrees to full extension.  Wrist is able to extend to neutral and does lack degrees to full extension.  Left lower extremity is held in extensor synergy pattern, with his plantar flexion and eversion, brought down to neutral.  NEUROLOGICAL:  He is alert and oriented x3.  Speech is clear.  No dysarthria.  He is appropriately following complex commands.  He has occasional repetitive movements on his right upper extremity, rubbing his right thigh.  Immediate recall 3/3 and 3/3 after 5 minutes.  He is able to recall the names of most of his physicians that he has seen in the past.  He is able to adduct.  Cranial nerves II through XII are intact.  Manual muscle testing in the right upper and lower extremities reveal 5/5 strength, left deltoid is 2, biceps are 2-, elbow flexion is on the left side, finger flexion is 2-.  Left hip flexion is 4-, knee extension is 4, ankle dorsiflexion is 4- and ankle plantar flexion is 3.  Muscle stretch reflexes are +2 throughout the right upper and lower extremity, +3 throughout the left upper and lower extremity with nonsustained clonus in the left ankle. 
 
FUNCTIONAL STATUS UPON DISCHARGE:  Please see rehabilitation course.
 
DISCHARGE DISPOSITION:  Home with family.
 
DISCHARGE THERAPIES:  He will receive speech therapy on an outpatient basis.  He will also receive home speech, occupational and physical therapy through the VNA.
 
DISCHARGE MEDICAL EQUIPMENT:  Wheelchair and bedside commode through Medicare.



DATE OF ADMISSION:  MM/DD/YYYY

DATE OF DISCHARGE:  MM/DD/YYYY

DISCHARGE DIAGNOSES:
1.  Postsurgical care, status post left total knee arthroplasty secondary to osteoarthritis.
2.  Hypertension.
3.  Type 2 diabetes mellitus.

CONSULTS:  The patient followed with Dr. Doe, who removed the patient’s staples and evaluated the patient’s knee.

PROCEDURES:  None.

ALLERGIES TO MEDICATIONS:  MORPHINE.

WOUND CARE:  None.

HOME HEALTH CARE:  The patient will receive ongoing physical and occupational therapy through (XX) Nursing Care.  They will also do prothrombin times and INR.

DISCHARGE LABORATORY DATA:  Prothrombin time from MM/DD/YYYY showed a PT of 13.6, INR 1.4, and that was on 9 mg of Coumadin daily.  Glucose 114, BUN 21, creatinine 0.9, sodium 137, potassium 4.5, chloride 99, CO2 of 29, and calcium 8.8.

HOSPITAL COURSE:
1.  Postsurgical care, status post left total knee arthroplasty.  The patient is a (XX)-year-old female who suffered from degenerative joint disease in her left knee.  As a result, the patient elected to undergo a left total knee arthroplasty.  Postoperatively, the patient suffered no complications.  Once stable, she was transferred to this facility for physical and occupational therapy in an effort to increase her level of mobility and independence prior to going home.  The patient’s biggest barrier in therapy was the stairs.  She has 24 stairs in her home, but the patient did well.  On discharge, she is able to ambulate 400 feet with standard walker independently.  She is able to go up and down 24 stairs with a rail and standard walker independently.  She is able to ambulate 150 feet with a cane with standby assistance.  Her active range of motion in her left knee is 80 degrees knee flexion.  The patient did use a CPM machine while here, and the last setting was 80 degrees knee flexion and 0 degrees knee extension.  She will have a CPM machine at home.  The patient’s staples were removed by Dr. Doe.  The wound remains clean, dry, and intact and shows no evidence of dehiscence, purulent drainage or odor.  The patient will follow up with him on MM/DD/YYYY.
2.  Hypertension.  The patient’s blood pressure was monitored daily and remained well controlled.  Her blood pressure remains between 122/52 to 142/86.  No changes were made in her antihypertensive medicines.
3.  Type 2 diabetes mellitus.  The patient’s blood sugars were monitored daily and they too remain well controlled.  Her insulin was changed to 70/30 and the patient’s blood sugars have been ranging between 86 and 120.  She was encouraged to continue this dose until she follows with her primary care physician.
4.  Gastroesophageal reflux disease.  The patient did experience heartburn and was being treated with Prevacid.  Prevacid did not help the patient as much as Nexium, so she was given Nexium 40 mg daily and this did resolve her heartburn problems.

DISCHARGE DIET:  Regular diet with no concentrated carbohydrates and stage IV liquids.  The patient will follow up with the outpatient dietary service here to receive some diabetic education.

MEDICAL EQUIPMENT:  Standard walker.

DISCHARGE MEDICATIONS:  Lasix 40 mg daily; hydralazine 10 mg q.i.d.; potassium 10 mEq daily; verapamil 240 mg b.i.d.; Nexium 40 mg daily; insulin 70/30, 50 units subcutaneously b.i.d.; Catapres patch 0.1 mg and 0.3 mg applied every Thursday; Coreg 25 mg q.12 h.; Diovan 320 mg daily; Coumadin 10 mg every evening, take last dose MM/DD/YYYY; Estraderm 0.05 mg patch apply every Mondays and Thursdays; iron 325 mg b.i.d. with food and Percocet 1 to 2 tablets q.4-6 h. p.r.n. pain.

CONDITION ON DISCHARGE:  Good.



Comments