Rehabilitation Medical Transcription History and Physical Sample Report


HISTORY OF PRESENT ILLNESS:  This is a (XX)-year-old male admitted to (XX) Hospital, MM/DD/YYYY, after falling in the bathtub and found to be unresponsive.  At (XX) Hospital, the patient was found to have a ruptured left middle cerebral artery aneurysm and right hemiplegia.  He underwent a left frontoparietal decompression, craniotomy and clipping of the aneurysm.  Hospital course was complicated by postoperative fever, increase in lethargy, electrolyte abnormalities and hypertension.  He was extubated on MM/DD/YYYY.  He had a nasogastric tube for tube feeding, but pulled this out two times.  Hospital records indicated he was on a pureed diet.  He had a PEG placed on MM/DD/YYYY.

1.  Kidney stones.
2.  Hypertension.

ALLERGIES:  No known medical allergies.

1.  Heparin 5000 units subcutaneously b.i.d.
2.  Nimotop 60 mg q.4 h.
3.  Neutra-Phos one packet q.i.d.
4.  Reglan 5 mg IV q.6 h.
5.  Zovirax topical 5 times per day x7 days.
6.  Keppra 1000 mg b.i.d.
7.  Magnesium oxide 400 mg b.i.d.
8.  Pepcid 20 mg b.i.d.
9.  Trazodone 25 mg at bedtime.
10.  Ritalin 2.5 mg every 0700 and 1300.

1.  Zantac 150 mg per tube b.i.d.
2.  Ritalin 5 mg at 0700 and 1300 per tube.
3.  Trazodone 50 mg per tube at bedtime.
4.  Tylenol per rectum or per tube 650 mg q.4 h. p.r.n.

SOCIAL HISTORY:  The patient is married.  The patient has smoked one pack per day for 30 years.  He does not drink alcoholic beverages.  He has no pets.  He is retired from (XX).  His hobbies include fishing, reading and building models.

FUNCTIONAL HISTORY:  Independent prior to admission.  Bed mobility, supine-to-sit, mod assist.  Transfers, sit-to-stand, min-to-mod assistance of 2.  Ambulate, 2 steps attempted, not performed.  Sitting balance for 15 minutes, min assist.  Upper and lower extremity ADLs, mod assist.  Bowel and bladder, max assist.  Feeding dependent.  Dysphagia I with semi-thick liquids.

FAMILY HISTORY:  Mother is alive and healthy at age (XX).  Father died of cancer, of an unknown type.  There is a grandmother with history of stroke.

LABORATORY DATA (FROM OUTSIDE HOSPITAL):  From MM/DD/YYYY, white blood cells 13,500, hemoglobin 10.4, hematocrit 30.3, platelets 285,000, MCV 91.2, sodium 138, potassium 4.1, chloride 102, CO2 24, BUN 13, creatinine 0.7, glucose 108, calcium 8.4, magnesium 1.7, and phosphorus 2.8.

REVIEW OF SYSTEMS:  Unable to obtain secondary to the patient being nonverbal.

PHYSICAL EXAMINATION:  VITAL SIGNS:  Vitals are pending.  HEENT:  Eyes open to voice.  Pupils are equal, round and reactive to light.  The patient makes good eye contact.  HEART:  Regular rate and rhythm.  LUNGS:  Clear to auscultation bilaterally.  ABDOMEN:  Positive bowel sounds, soft, PEG tube present.  EXTREMITIES:  Bilateral upper and lower extremity voluntary movement.  NEUROLOGIC:  The patient was awake, nonverbal, appeared fatigued, kept eyes closed, would open them intermittently with conversation.  He did follow command to squeeze with his right hand.  Deep tendon reflexes are 2+/4, bilateral biceps, brachioradialis and left patellar; 3+/4, right patellar.  Babinski is present on the right.

1.  The patient is a (XX)-year-old white male with left middle cerebral artery intracerebral hemorrhage secondary to ruptured aneurysm with right hemiplegia, status post decompression, craniotomy and clipping.
2.  Postoperative fever, lethargy and electrolyte abnormalities.
3.  Dysphagia.
4.  Hypertension.
5.  Right axillary deep venous thrombosis.

Plan is for full team rehabilitation, including physical therapy to evaluate and treat for mobility, transfers, balance and gait training.  Occupational therapy to evaluate and treat for activities of daily living.  Speech-language pathology to evaluate and treat for dysphagia and cognition, along with aphasia.  Recreation therapy to evaluate and treat for community re-entry.  Rehabilitation psychology to evaluate and treat for adjustment and depression.

Laboratory ordered will include complete blood count, comprehensive metabolic panel, prealbumin level, urinalysis culture and sensitivity, along with total and free testosterone level.

We will also order a sleep log and sleep study to check for sleep hypopnea.  Trazodone will be ordered for sleep hygiene.  Ritalin will be ordered for fatigue.  In addition, amantadine will be added for attention and fatigue.

For safety, we will order a reverse belt for the wheelchair and locked belt for bed.  We will further assess for the need for wrist restraints.

For DVT prophylaxis, we will order TED hose and sequential compression devices, along with heparin subcutaneously b.i.d.

For bowel and bladder prophylaxis, we will order MiraLax and Senokot.

For nutrition and hydration, we will order Ultracal HN Plus at 40 mL per hour and increasing by 20 mL q.4 h. to goal rate of 80 mL per hour.  In addition, we will order 250 mL of water bolus q.6 h.

HISTORY OF PRESENT ILLNESS:  The patient is a (XX)-year-old right-handed female with a long-standing history of hypertension and diabetes who was admitted for complications of diabetic amyotrophy and nerve root compression.  Initially, the patient presented to the ER at the outside hospital on XX/XX/XXXX with complaints of acute onset of bilateral lower extremity weakness.  While she was in the shower, she experienced onset of low back and pelvic pain and anterior thigh pain and then her lower extremities became weak.  She did not fall or have any kind of injury or trauma at that time but did experience trouble standing and imbalance.  She denied any vertigo, presyncope, chest pain or shortness of breath at that time.  The patient states that one week prior she was on aspirin and Zocor but that was discontinued for unknown reasons, which she could not state.  She was admitted to the outside hospital with an L3-L4 mild stenosis and L4-L5 spinal facet disease and L5-S1 paracentral and foraminal disk herniation with L5-S1 root compression and narrowing of the L5 neural foramen.  There was no surgical intervention deemed necessary.  The patient’s symptoms and complications have been attributed to her diabetic amyotrophy and bilateral plexus cord ischemia secondary to her unmanaged diabetes.  The patient has a history of noncompliance with her diabetes regimen.  There is also documented peripheral neuropathy and polyradicular symptoms, as well as an age-indeterminate right parietal stroke.  Her hospital stay has been uneventful thus far at the outside hospital.  She did have a UTI with E. coli which was treated with ciprofloxacin.  Her initial imaging was a spinal MRI, which showed the following; a large broad-based left paracentral foraminal disk herniation at L5-S1 with compression in the region of the proximal left S1 root and narrowing of the left L5 neural foramen, mild central stenosis at L3-L4 related to diffuse disk bulge and facet hypertrophy and severe facet arthropathy at L4-L5.  She also had a head MRI and MRA of her vessels, which showed nonspecific white matter abnormalities but no vascular occlusion or lesions identified.
PAST MEDICAL HISTORY:  Gastroesophageal reflux disease, diabetes, hypertension, hyperlipidemia, status post rheumatic fever, bilateral carpal tunnel syndrome, diabetic neuropathy, obesity, status post cholecystectomy, asthma, history of gout, hiatal hernia.
FAMILY HISTORY:  Lung cancer, breast cancer, hypertension.
SOCIAL HISTORY:  She lives with her husband in a single level home.  It is a one-floor dwelling with no steps to enter.  Denies any tobacco, alcohol or drugs.  She does have durable medical equipment at home including a shower chair, wheelchair, cane and hospital bed.
ACTIVITY:  Weightbearing as tolerated.
DIET:  Cardiac, diabetic, regular stage IV.
ALLERGIES:  Iodine and Flagyl.
MEDICATIONS:  Hydrochlorothiazide 100 mg p.o. daily, Prinivil 40 mg p.o. daily, Cozaar 100 mg p.o. daily, atenolol 100 mg p.o. b.i.d., Prevacid 30 mg p.o. daily, heparin 5000 units subcutaneously b.i.d., penicillin 250 mg p.o. daily for suppressive therapy of rheumatic fever, Glucophage 500 mg p.o. b.i.d., ciprofloxacin 500 mg p.o. b.i.d. x3 days, Vicodin p.r.n., Tylenol p.r.n., Vancenase nasal spray p.r.n., aspirin 81 mg p.o. daily, sliding scale insulin.
REVIEW OF SYSTEMS:  Low back pain, otherwise negative.
PHYSICAL EXAMINATION:  VITAL SIGNS:  Temperature 97.7 degrees, blood pressure 147/87, pulse 82 and respirations 21.  GENERAL APPEARANCE:  In no acute distress.  HEENT:  Pupils are equal, round and reactive to light.  Extraocular movements are intact.  No scleral icterus.  Oropharynx clear.  No lesions, no erythema or exudate.  Tongue and uvula are midline.  Neck:  Soft and supple.  No LAD.  No JVD.  CARDIOVASCULAR:  Regular rate and rhythm.  No murmurs, rubs or gallops.  PULMONARY:  Clear to auscultation bilaterally.  No wheezes, crackles or rhonchi.  ABDOMEN:  Obese.  Positive bowel sounds in all four quadrants.  Mildly tender to palpation in right lower quadrant.  No acute peritoneal signs.  No rebound, guarding, fluid wave or ascites.  EXTREMITIES:  Warm to touch x4.  No cyanosis, no clubbing, trace bilateral pedal edema, 2+ dorsalis pedis pulses.  Moves all extremities x4.  Calf measurement 31.5 cm bilaterally.  Thigh measurement 62 cm bilaterally.  NEUROLOGICAL:  Alert and oriented x4.  Follows 100% and appropriate.  Cranial nerves II through XII were intact.  Manual muscle testing 5/5 in bilateral upper extremities.  Manual muscle testing, lower extremities, right lower extremity; hip flexion was 3+, knee extension 4+, ankle dorsiflexion 5, EHL 5, ankle plantarflexion 5.  Manual muscle testing, left lower extremity; hip flexion 2+, knee extension 4-, ankle dorsiflexion 4, EHL 4+, and ankle plantarflexion 4+.  Muscle stretch reflexes were 1+ for biceps, triceps and brachioradialis on the right upper extremity, 1+ for brachioradialis and triceps on the left upper extremity and 2+ for biceps on the left upper extremity.  Reflexes were 0 and absent in the lower extremities bilaterally.  The patient did have downgoing toes on Babinski exam.  No Hoffmann.  No clonus.  Sensation was decreased to light touch and pinprick in L5 distribution, left side greater than right.  Cerebellar testing, finger-to-nose was within normal limits bilaterally.  Tone was within normal limits.  Spasticity was absent.
1.  Rehabilitation:  The patient is a (XX)-year-old female status post symptoms as described above.  Her weakness and need for therapy at this time are due to her diabetic amyotrophy.  She is basically minimum to moderate assistance with her PT/OT activities.  She has fair rehabilitation potential, and she will be admitted for acute intensive inpatient rehabilitation including physical, occupational, speech and therapeutic recreation as well as psychology, social work and nutrition services.  Estimated length of stay is three weeks.
2.  Spine:  Stable.
3.  Neurology:  No current issues.  We will follow up as an outpatient.
4.  Deep venous thrombosis prophylaxis:  On subcutaneous heparin.
5.  Pain control:  On p.r.n. Vicodin, Tylenol and Motrin.
6.  Infectious disease:  She is on long-standing penicillin for suppressive therapy of rheumatic fever.  She also has UTI at this time.  Due to E. coli bacteremia in her urine, she is on ciprofloxacin and has three more days of antibiotic, and UA will be rechecked after her antibiotic is completed.
7.  Feeding and nutrition:  She is on a cardiac, diabetic, regular stage IV diet.
8.  Bowel.  Her last bowel movement was three days ago.  She will be placed on senna-S two tablets p.o. q.a.m. and Dulcolax suppository q.h.s.
9.  Bladder program:  Her postvoid residual will be checked and intermittent straight catheterization will be instituted q.4-6 h. p.r.n. to ensure bladder volumes less than 450 mL.
10.  Skin:  No active issues or open skin at this time.  We will monitor.
11.  Spasticity and tone.  Within normal limits.
12.  Endocrine:  The patient has long-standing history of uncontrolled diabetes.  She is on metformin with questionable compliance in the past.
13.  Her fingerstick blood sugars will be checked.  She will be placed on sliding scale insulin, and we will check hemoglobin A1c.
14.  Gastrointestinal prophylaxis:  She is on Prevacid.
15.  Sleep:  A sleep log will be ordered and she has p.r.n. trazodone.
16.  Psychology to evaluate behavior and mood.  P.r.n. Ativan for anxiety.
17.  Cardiovascular:  She has a significant history of hypertension, and she will be managed on her current regimen of hydrochlorothiazide, Prinivil, Cozaar and atenolol, and we will have p.r.n. hydralazine provided for elevated systolic or diastolic blood pressures.
18.  Admit labs:  Will be followed up.
19.  Followup appointments:  With Neurology.
20.  Code status:  Full.