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Physical Medicine and Rehab Medical Transcription SOAP Note

SUBJECTIVE: The patient is without complaints, except he would like his baclofen pump addressed so that he can focus his attention on improving his functional abilities.

OBJECTIVE: The patient is afebrile with vital signs stable. The patient is 5 feet 8 inches tall and weighs 156 pounds. The head and neck are unremarkable. Pupils are equal, round, and reactive to light. Extraocular movements are intact. The patient is wearing eyeglasses. There is no apparent facial asymmetry. Heart and lung examinations are within normal limits. The abdomen is soft and nontender with active bowel sounds. A baclofen pump was noted in the left lower quadrant of the abdomen. Knee-high Ace wraps/compression stockings were in place.

ASSESSMENT AND PLAN:
1. Rehabilitation: A team conference was held today to review the patient’s functional goals and progress. The patient requires standby assistance with stand pivot transfers. The patient is independent with catheterization using a Coude catheter. Standby assistance/supervision is required for feeding, grooming, for bathing at the transfer tub bench, for upper extremity dressing, for bowel management, and for bed to wheelchair transfers. Minimal assistance is required for lower extremity dressing, bladder management, toilet transfers, and tub transfers. Based on the patient’s functional goals and progress, his tentative discharge date was established. The patient was told of this and was in agreement with the plan. However, he would like to focus on his baclofen pump for a portion of the rehabilitation stay. Continue comprehensive inpatient rehabilitation.
2. Spasticity: Under fair control. The neurologist will be contacted as far as further evaluation of the baclofen pump is concerned. A dye study is yet to be done.
3. Pain: Under fairly good control. Continue present management.
4. Bladder management: As previously mentioned, the patient is independent with intermittent catheterization. Continue present management.
5. Bowel management: Improving. Continue to work on a regulated program.
6. Hypertension: Under fair control. Continue present management.
7. Lower extremity edema: Improving. The lymphedema management team is assisting with his care.
8. Dementia: Workup in progress. The patient continues to be seen by the neurologist.

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