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Physical Medicine and Rehab Medical Transcription Sample

DATE OF ADMISSION:  MM/DD/YYYY

CHIEF COMPLAINT:  Impaired mobility, self-care.

HISTORY OF PRESENT ILLNESS:  The patient is a (XX)-year-old female who was initially admitted for complaint of weakness and associated depression. The patient did have open-heart surgery for mitral valve replacement about 2 months ago with a prolonged course where she completed rehab and was discharged to home. Since then, she had been doing poorly; hence, she was readmitted for the above symptoms. Further workup with an echocardiogram revealed presence of left atrial thrombus. An EKG revealed atrial fibrillation so Coumadin was initiated and Lovenox also along with amiodarone. Cardioversion was not done.

The patient underwent a pacemaker placement previously and the pacemaker was rechecked again, which revealed normal function. Psychiatric service was also consulted for evaluation of depression and Remeron was initiated. GI services were consulted for nausea and the patient was placed on Zofran. The patient was also found to have an esophageal ulcer, gastritis via endoscopy and was recommended proton pump inhibitors daily. She also had ongoing issues with back pain secondary to her history of spinal stenosis and was continued on pain management. It was finally recommended by the cardiology service that cardioversion would be done at a later date, so the patient was recommended to continue with Coumadin anticoagulation, amiodarone and also digoxin and Coreg.

Physical and occupational therapies were initiated, and because of functional decline, it was recommended that the patient would benefit from active rehabilitation, so the patient was transferred and admitted for further comprehensive inpatient rehab program.

REVIEW OF SYSTEMS:  The patient denies any chest pain, shortness of breath or abdominal pain. She denies any headache. There is just generalized weakness. Otherwise, 10-system review is negative.

ALLERGIES:  PENICILLIN.

PAST MEDICAL HISTORY:  CVA; COPD; left breast mastectomy; insomnia; atrial fibrillation; spinal stenosis with chronic back pain; hypercholesterolemia; sleep apnea, on CPAP and home oxygen; also she is status post recent mitral valve replacement; osteoporosis with multiple compression fractures.

MEDICATIONS:  Calcium 1 tablet p.o. daily, Arimidex 1 mg p.o. daily, Coreg 12.5 mg p.o. q. 12 hours, Coumadin 3 mg p.o. tonight, digoxin 125 mcg p.o. daily, K-Dur 10 mEq p.o. daily, Lasix 20 mg p.o. daily, Lidoderm patch topically daily for 12 hours, multivitamin 1 tablet p.o. daily, Mylanta 30 mL p.o. p.r.n., omeprazole 40 mg p.o. q.a.m., Reglan 10 mg p.o. q.i.d. before meals and at bedtime, Tylenol 650 mg p.o. q. 4-6 hours p.r.n., Zocor 20 mg p.o. at bedtime, Zoloft 75 mg p.o. daily, Zofran 4 mg p.o. q. 8 hours p.r.n., Tylenol No. 3 one tablet p.o. q. 6 hours p.r.n.

SOCIAL HISTORY:  The patient lives with family. Denies any smoking or tobacco use.

FUNCTIONAL HISTORY:  Prior to admission, the patient was ambulating with a cane and a walker. Currently, bed mobility is moderate assist, ambulation 15 feet with minimum to moderate assist.

PHYSICAL EXAMINATION:
VITAL SIGNS:  Stable. The patient is afebrile.
GENERAL:  The patient is alert and oriented x2. Cognition reveals impaired memory recall, 2/3, and impaired abstract reasoning judgment.  There is flat affect. Speech is fluent without any dysarthria.
HEENT:  Pupils are equal, round and reactive to light and accommodation.
LUNGS:  Clear to auscultation.
CARDIOVASCULAR:  Regular rate and rhythm.  Normal heart sounds.
ABDOMEN:  Soft, nontender, nondistended with good bowel sounds.
EXTREMITIES:  Reveal no lower extremity edema or calf tenderness.
NEUROLOGIC:  Motor strength in bilateral upper extremities is 4-/5, lower extremities are also 4-/5. Sensation and tone and coordination are normal. There is mild bilateral generalized tremor in all extremities. The reflexes are 2+. Sitting balance is fair. Gait was not tested.

ASSESSMENT AND PLAN:
1.  Deconditioning, history of recent open-heart surgery/mitral valve replacement, left atrial thrombus. We will initiate physical and occupational therapy for ambulation, mobility, gait training, transfers and self-care and for adaptive equipment. Continue cardiac precautions.
2.  History of atrial fibrillation. Continue Coumadin and amiodarone and also digoxin and Coreg. Currently, the patient is waiting for cardioversion at a later date after the patient has improved functionally.
3.  Depression. Continue Zoloft. Monitor mood. Neuropsychology will be reinitiated for coping issues.
4.  Pain management. With Lidoderm patch, Tylenol No. 3 for history of spinal stenosis.
5.  Hyperlipidemia. Continue Zocor.
6.  Gastrointestinal prophylaxis, history of the esophageal ulcers and gastritis as per endoscopy. Continue omeprazole.
7.  Gallbladder, per protocol.
8.  Safety. Maintain fall precautions.
9.  Sleep apnea. Continue CPAP.
10.  Social services for discharge planning.
11.  Bowel and bladder. As per protocol.

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