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Rehab Consultation Sample Report / Transcription Example

DATE OF CONSULTATION:  MM/DD/YYYY

REFERRING PHYSICIAN:  John Doe, MD  

REASON FOR CONSULTATION:  Spinal cord compression.

HISTORY OF PRESENT ILLNESS:  The patient is a (XX)-year-old right-handed woman who was recently diagnosed with multiple myeloma, currently on thalidomide and Decadron treatment, who was admitted after having suffered a compression fracture 1 week prior to admission. She was complaining of increased low back pain, lower extremity paresthesias and weakness. She was very fatigued. Her hemoglobin was 8.2. She was transfused. She was found to have a right middle and lower lobe infiltrate and/or effusion. Chest CT scan revealed a large right pleural effusion and a small left pleural effusion. A lesion in the left liver lobe was seen. Lumbosacral MRI examination was unremarkable except for spondylosis. A thoracic MRI examination revealed a T6 paraspinous lesion with spinal cord compression. The patient was transferred to this facility and was started on increased steroids and radiation therapy. It was felt that she was not a surgical candidate due to the risks outweighing the benefits. The patient did undergo a right thoracentesis and 1300 mL of fluid was removed. Final pathology is pending. She has 2 radiation treatments left. She has not had any significant return of lower extremity movement. PICC line placement is pending for tomorrow. The patient states that she is not having any significant pain. She is sleeping fairly well. She has not had any good bowel movements. Appetite is fair.

PAST MEDICAL HISTORY:  Hypertension, depression and hypercholesterolemia. She is status post cholecystectomy, tubal ligation, toe surgery and right breast cyst removal.

ALLERGIES:  CODEINE.

MEDICATIONS:  Heparin 5000 units subcutaneously q.12 h., oxygen 2 liters per nasal cannula, hydrochlorothiazide 25 mg daily, Zetia 10 mg daily, Levaquin 500 mg daily, Decadron 4 mg q.i.d., Zoloft 25 mg daily, thalidomide 200 mg daily, Colace 100 mg b.i.d., Inderal 10 mg b.i.d., Procrit 40,000 units subcutaneously, Darvocet-N 100 one to two tablets q.3-4 h. p.r.n. for pain and lactulose 30 mL p.o. p.r.n.

HOME MEDICATIONS:  Hydrochloride 25 mg daily, Inderal 10 mg daily, Zetia 10 mg daily, Zoloft 25 mg daily, thalidomide 200 mg daily and Decadron.

DIET:  Regular. 

FUNCTIONAL STATUS:  The patient has a Foley catheter. She was in urinary retention with high residuals. She has been incontinent of a few small bowel movements. She requires maximal assistance for bed mobility and she is dependent for transfers. She is not ambulatory. She requires setup for feeding. She requires assistance for grooming. She is dependent for other self-care. She was independent prior to admission.

SOCIAL HISTORY:  The patient is married. She has 3 sons and 2 daughters. The family is very supportive. She lives in a home with 2 steps to the entrance. There is a bathroom and living area on the first level. There are 9 stairs up to where her main bedroom and bathroom are located. The patient does not smoke. She does not drink. She is retired.

FAMILY HISTORY:  Noncontributory. 

REVIEW OF SYSTEMS:  Per the HPI and PMH. She wears glasses. No cataracts or glaucoma. No hearing difficulties. No GI or GU difficulties. No other neurological problems. No other musculoskeletal problems. No endocrine disorders.

PHYSICAL EXAMINATION:
VITAL SIGNS:  Temperature 98.6, pulse 84, respirations 22, blood pressure 114/64. Height 5 feet 4 inches, weight 165 pounds. Her oxygen saturation is 98% on 2 liters of oxygen per nasal cannula.
GENERAL APPEARANCE:  A well-developed, well-nourished, overweight woman, in no acute distress. Her affect was somewhat flat. Multiple family members were present during the interview and examination.
HEENT:  NC/AT. Nasal cannula was in place.
NECK:  Without bruits.
LUNGS:  Clear except for some decreased breath sounds in the right base.
HEART:  Regular rate and rhythm without murmur.
ABDOMEN:  Obese. Bowel sounds are positive, soft, nontender and slightly distended. 
EXTREMITIES:  No clubbing, cyanosis or edema. No calf erythema, warmth or tenderness. Peripheral pluses strong and symmetric. Passive range of motion within functional limits throughout.
SKIN:  Intact.
RECTAL:  The patient declined at this time.
NEUROLOGIC:  Mental Status:  The patient was alert and oriented x3. She did not demonstrate any gross cognitive or language deficits. Cranial nerves II through XII intact. Motor:  There was decreased tone in the lower extremities. There was normal tone in the upper extremities. No atrophy was noted. Strength was normal in the upper extremities. Movement was absent in the bilateral lower extremities except for trace right ankle movements. Muscle Stretch Reflexes:  Absent ankle jerks and knee jerks bilaterally. The upper extremities were 2+ throughout. Toe response was equivocal bilaterally. Hoffmann sign was negative bilaterally. Coordination:  Intact in the upper extremities. Not applicable in the lower extremities. Sensory:  Sensation was decreased from the T7 dermatome and distally. Sensation was intact proximal to the T7 dermatome. She had decreased pinprick. Gait:  Not applicable.

LABORATORY DATA:  Echocardiogram showed that there was abnormal septal motion, probably secondary to intraventricular conduction delay. She had stage I diastolic dysfunction. Hemoglobin 9.8, white blood cell count 2800 and platelet count 84,000. Sodium 133, potassium 3.5, chloride 88, bicarbonate 24, BUN 15, creatinine 0.9, glucose 134, calcium 7.8 and albumin of 1.9.

ASSESSMENT:
  1. Incomplete paraplegia.
  2. Multiple myeloma with spinal cord compression.
  3. Neurogenic bladder and bowel.
  4. Right pleural effusion, status post thoracentesis with final pathology pending.
  5. Hypoxia.
  6. Anemia, status post transfusion.
  7. Pancytopenia.
  8. Left liver lobe lesion.
  9. Hypertension.
  10. Hypercholesterolemia.
  11. Hyponatremia.
  12. Decreased nutrition.
  13. Depression.
RECOMMENDATIONS:  Physical therapy will continue. Occupational therapy will be added. The patient is appropriate for rehabilitation to work on mobility and self-care, as well as patient and family education and training. I would estimate a length of stay of 2 to 3 weeks. This would be followed by home health services. The patient will be placed on a bowel program. The importance of this was discussed with the patient and her family. Her Zoloft could be increased to 50 mg daily due to her depression. Her skin needs to be monitored closely and she needs to be turned frequently. I would recommend adding protein shakes to improve her nutritional status. The assessment and recommendations were discussed with the patient and her family.

Thank you, Dr. Doe, for allowing me to participate in the care of this patient..