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Physical Medicine and Rehabilitation Medical Transcription Transcribed Sample

DATE OF ADMISSION:  MM/DD/YYYY

DATE OF DISCHARGE:  MM/DD/YYYY  

ADMITTING DIAGNOSES:
1.  Posttraumatic osteoarthritis, left knee.
2.  Status post unicondylar arthroplasty.
3.  Anemia.
4.  Depression.
5.  Anxiety.
6.  Antiphospholipid syndrome.
7.  History of motor vehicle accident.

REASON FOR ADMISSION:  Functional deficits secondary to left unicondylar arthroplasty.

CHIEF COMPLAINT:  Left knee pain.

HISTORY OF PRESENT ILLNESS:  This is a (XX)-year-old female admitted secondary to progressive left knee pain, history of MVA, with increasing pain and decreasing function.  The patient failed conservative treatment.  Underwent left unicondylar knee arthroplasty by Dr. Doe.  No postoperative complications reported.  Discharged to subacute rehabilitation for restorative therapies to achieve optimized level of functioning.

PAST MEDICAL HISTORY:  Anemia, depression, anxiety, posttraumatic stress disorder, and antiphospholipid syndrome.

PAST SURGICAL HISTORY:  Cholecystectomy, varicose vein excision, bilateral knee arthroscopy, multiple back and neck surgeries.

FAMILY HISTORY:  Noncontributory.

SOCIAL HISTORY:  Lives alone.  Positive smoker.  Occasional alcohol.  Prior to admission, the patient was independent.

ALLERGIES:  CEPHALOSPORINS.

MEDICATIONS:  At the time of admission to subacute rehabilitation; Coumadin, Lortab, Colace, and Lovenox.

REVIEW OF SYSTEMS:  Negative for chest pain, palpitation.  Negative for cough, shortness of breath.  Negative for headache, nausea, vomiting.  Negative for fever, chills, night sweats.  Negative for rash, itching.  Negative for dysuria, hematuria.  Negative for abdominal pain, constipation or diarrhea.

PHYSICAL EXAMINATION:
GENERAL:  Revealed a well-developed, well-nourished female, in pain.
VITAL SIGNS:  Blood pressure 110/66, temperature 98.5, respirations 18, and heart rate 72.
HEENT:  Oral mucosa moist.  Sclerae anicteric.  Vision intact.  Hearing intact.
NECK:  Supple.  No JVD.  No thyromegaly.
BREASTS:  Exam was deferred.
LUNGS:  Clear to auscultation.
HEART:  S1, S2, sinus tachycardia.
ABDOMEN:  Soft and nontender without masses.
EXTREMITIES:  Calves soft, nontender.  Left knee incision; staples, erythema, minimal drainage, tenderness.
LYMPH:  Not tested.
NEUROLOGIC:  Alert and oriented x3.  Bilateral upper extremities 5/5, right lower extremity 5/5, left extensor hallucis longus 5/5.
PSYCHIATRIC:  Affect and mood appropriate.

HOSPITAL COURSE AND TREATMENT:
1.  Left knee posttraumatic osteoarthritis, status post unicondylar knee arthroplasty.  The patient was initiated into subacute rehabilitation program including daily PT and OT with weightbearing as tolerated.  Wound was monitored and pain was controlled.  Staples were removed on day of discharge with Steri-Strips applied.  Wound was noted to be healing well.  She will continue with in-home PT and follow up with Dr. Doe as instructed.  From a functional standpoint, at the time of discharge, she was independent with eating, grooming; minimal assist for ADLs; independent with bed mobility and transfers; and ambulating 50 feet, standard walker, supervision.
2.  Anemia.  She remained clinically stable.
3.  Depression and anxiety.  Was initially at home on Lexapro and trazodone as well as Klonopin.  Lexapro and trazodone were reinitiated.
4.  DVT prophylaxis.  Continued on Coumadin and Lovenox for bridging until Coumadin therapeutic.
5.  Antiphospholipid syndrome.  She was maintained on Coumadin.

PROCEDURES PERFORMED:  None.

CONSULTS OBTAINED:  None.

CONDITION AT DISCHARGE:  Stable.

DIET:  Regular.

ACTIVITY:  Weightbearing as tolerated, left lower extremity.

DISCHARGE DIAGNOSES:
1.  Posttraumatic osteoarthritis.
2.  Status post left unicondylar knee arthroplasty.
3.  Anemia.
4.  Depression/anxiety.
5.  Antiphospholipid syndrome.
6.  History of motor vehicle accident.

DISCHARGE INSTRUCTIONS:  Follow up with Dr. John Doe on MM/DD/YYYY at 9:30.  Follow up with Dr. Jane Doe in 1 to 2 weeks.  The patient to call for appointment.  Maintain weightbearing as tolerated, left lower extremity.  VNA for in-home PT.  Nurse for PT/INR biweekly.

DISCHARGE MEDICATIONS:  Lortab 7.5 one every 4 hours p.r.n. pain, trazodone 200 mg at h.s., Celexa 60 mg daily, Colace 100 mg b.i.d., and Coumadin 6 mg daily.

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