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Sample Physiatric Reports - Progress Note Transcription Example

SUBJECTIVE: The patient states that she is excited about being on the rehabilitation unit so she can gain the necessary skills to head on home. She feels her pain is under fairly good control.

OBJECTIVE: Temperature 99.2 degrees, pulse 95, respirations 18, and blood pressure 134/89. The head and neck examination was unremarkable with pupils equal, round and reactive to light and extraocular movements intact. She had normal hearing acuity. She had good dentition with moist nasal and oral mucosa. Neck examination was unremarkable with no evidence of lymphadenopathy or thyromegaly. The lungs were clear to auscultation without rales, rhonchi or wheezes. The heart had a regular rate and rhythm without murmur. The abdomen was somewhat protuberant, but otherwise soft, nontender, with active bowel sounds. There was no guarding or rebound tenderness. There was no apparent hepatosplenomegaly. The patient wore a right short leg cast made out of plaster. Knee-high TED hose was worn on the left. Good capillary refill was noted at both great toes. There was at least one fingerbreadth of space between the edge of the cast and the calf on the right. Range of motion appeared to be within functional limits, although this could not be tested at the right ankle. Neurologic examination showed the patient to be alert and oriented x4 with mental status within normal limits. Mini-mental status exam had a score of 30/30. Cranial nerves II through XII were grossly intact. There was no apparent sensory deficit to pinprick or light touch. Reflexes were 3+ and symmetric throughout, except at the left ankle where it was 2+. Normal tone and 5/5 strength were noted in the upper extremities. Lower extremities showed iliopsoas strength of 3/5 on the right and 2+/5 on the left, quadriceps strength of 4-/5 bilaterally, anterior tibialis was 5/5 on the right and unable to be tested on the left, extensor hallucis longus was 4+/5 bilaterally, and gastrocnemius was 5/5 on the left and unable to be tested on the right because of the cast. The patient demonstrated fair truncal balance. Hoffmann and Babinski signs were absent.

ASSESSMENT AND PLAN:
1. Rehabilitation: The patient was admitted today from an outside hospital to begin comprehensive rehabilitation for her multiple trauma. Her trauma includes displaced fractures of the left transverse processes of the lumbar spine, superior and inferior left pubic rami fractures, widening of the left sacroiliac joint, and diastasis of the sacroiliac joint on the right. Liver contusion and contusion of the right kidney was also noted. She also has a right lower extremity pilon fracture. Comprehensive inpatient rehabilitation will work to maximize the patient’s functional abilities to the independent/modified independent level with all activities of daily living, initially at the bed level and progressing to standing using a walker, also will work to regulate the patient’s bowel/bladder function, provide adequate pain relief, maintain the cast on the right with weightbearing as tolerated on the left, provide patient/family education, address issues related to disability and sexuality, and address discharge planning. We will also make sure that there is no component of brain injury. This is unlikely because there was no loss of consciousness or history of trauma to the head. Rehabilitation Potential: Good. Estimated Length of Stay: Two to three weeks.
2. Multiple trauma: Stable. Continue to use cast on the right leg for the pilon fracture and weightbearing as tolerated for the left lower extremity. We will arrange followup with the outside hospital and orthopedic services.
3. Bowel/bladder management: We will work towards regulated programs for both. The patient had a Foley catheter removed a few days ago and will check for urinary tract infection by urinalysis, culture and sensitivity today. We will make sure that the patient has soft-formed stools and is not constipated.
4. Pain: Under good control. Continue Percocet as written.

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