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REHABILITATION (REHAB) HISTORY AND PHYSICAL SAMPLE

CHIEF COMPLAINT:  Status post left total knee replacement.


HISTORY OF PRESENT ILLNESS:  The patient is a (XX)-year-old male who has a history of left knee trauma.  Subsequently, arthroscopies were performed on bilateral knees.  Subsequently, the patient had a reinjury to the left knee.  He had increasing persistent pain and decreased function consistent with terminal degenerative joint disease.  Conservative management was accomplished.  The patient underwent elective procedure on MM/DD/YYYY for left total knee replacement by Dr. Doe.  Postoperatively, the patient had hypertension episode consistent with analgesic medication.  The patient was transferred to rehab on MM/DD/YYYY without problems.


PAST MEDICAL HISTORY:  History of hypertension and osteoarthritis.  He denied previous history of CVA, MI, seizure activity or head trauma.


PAST SURGICAL HISTORY:  Status post bilateral knee arthroscopies.


PSYCHOSOCIAL HISTORY:  The patient is married, lives in a single level home, has a couple of steps inside the home.  Wife is healthy.  Denies any use of tobacco products or alcohol consumption.


FAMILY HISTORY:  Noncontributory.


ALLERGIES:  PENICILLIN.


MEDICATIONS:  Zestril 20 mg daily, Pepcid 20 mg daily, and Restoril 15 mg at bedtime p.r.n.


REVIEW OF SYSTEMS:  Denies fever, chills, nausea, vomiting, shortness of breath or chest pain.


PHYSICAL EXAMINATION:
General:  Examination reveals a pleasant male.  He is comfortable.
Vital Signs:  Blood pressure 128/77, pulse 79, respirations 18, and temperature 97.6 degrees.
Skin: Warm and dry.  The incision area on the left knee is without drainage.  The right knee incision is well healed.  There is no pressure or decubitus ulcer identified.
HEENT:  Normocephalic.  Extraocular movements are intact.  Oropharynx is clear.  Trachea is midline.  Laryngeal elevation is good.
Chest:  Symmetrical bony structures.
Lungs:  Clear to auscultation.
Heart:  Regular rhythm and rate.  No murmurs or gallops.  Peripheral pulses are 2+ and symmetrical.
Abdomen:  Benign.  Active bowel sounds.  No tenderness on deep palpation noted.
Extremities:  All extremities are normal in alignment.  Good plantar surfaces for weightbearing purposes.  The left knee has 1+ effusion as well as left lower leg 1+ edema.  Range of motion is –5 to 30 degrees with some tenderness noted.  No displacement.  The knees appear to be stable.  No clubbing or cyanosis noted.
Neurological:  Alert and orientated x3.  Motor and sensory are intact, except for examination of the left knee limited postoperatively.  Sensory is intact, light touch and proprioception.  Cerebellum is intact with midline alternating movement.  Tone is symmetrical.  No spasticity or clonus.  Reflexes are symmetrical except for left knee, not tested.  Mentation is appropriate.  No overt depression or major anxiety.


REHABILITATION POTENTIAL:  Good to achieve home discharge at modified independent/independent level.


REHABILITATION ELOS:  Anticipated 5 to 7 days to accomplish ambulation more than 200 feet with assistive devices, transfers and self-care skills at modified independent/independent level with knee flexion at 90 degrees.


REHABILITATION ASSESSMENT:
1.  Status post left total knee replacement complicated with a previous history of right knee arthroscopy and anterior cruciate ligament repair.
2.  History of hypertension.
3.  Osteoarthritis.


PLAN AND SUMMARY:  This is a (XX)-year-old male who is a good rehabilitation candidate to achieve home discharge in 5 to 7 days at a modified independent/independent level.  It is anticipated that the patient would benefit from following physical therapy, occupational therapy, increased strength, overall function, and develop home exercise program.  Nursing will continue with wound care and monitor vital signs.  Care management will assist with discharge planning.  Rehabilitation physicians will maintain optimal medical status as well as coordinate discharge planning and followup care as needed.


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