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Rehabilitation Discharge Summary Transcription Sample

1. History of cerebellar artery aneurysm and multiple neurosurgical interventions, status post ventriculoperitoneal shunt and aneurysm coiling procedure.
2. Cardiomyopathy.
3. Hypertension.
4. History of anxiety.
5. Diplopia.
6. Cognitive deficits.

HISTORY OF PRESENT ILLNESS: This is a (XX)-year-old female who presented initially after she passed out in her car. CT scan revealed subarachnoid hemorrhage and aneurysm. Also, the patient was hypoxic during the angiogram. Cardiology was consulted and she was found to be in pulmonary edema. The patient was ruled out for a myocardial infarction, and echocardiogram revealed ejection fraction of 25%, possible hypertension, moderate tricuspid regurgitation, and mild mitral regurgitation. She also had hypokinetic inferior basilar and anterior septal wall deficits. That was the extent of the cardiology workup, and the major concern was related to subarachnoid hemorrhage. Glasgow coma scale of 10. Angiogram revealed a left superior cerebellar artery aneurysm. An intraventricular catheter was placed and she had distended ventricles, and about 6 weeks ago, a coiling procedure was performed. The followup CT scan revealed decreased ventricular size, decreased subarachnoid hemorrhage, but left and right cerebellar infarcts. On MM/DD/YYYY, angiogram revealed a basilar artery vasospasm with opacification of the superior cerebellar artery, and the patient was started on HHH therapy. On MM/DD/YYYY, she required a plasty of the left supraclinoid intracerebellar artery and dilatation of the left A1. On MM/DD/YYYY, she had new pronator drift and diagnosis of multiple vessel vasospasm. Intraventricular catheter was removed on MM/DD/YYYY and a VP shunt was placed. The patient then appeared to have finally stabilized and was transferred here for rehabilitation.

HOSPITAL COURSE: During rehabilitation here, the patient participated in physical therapy, occupational therapy, speech language pathology, and recreation therapy. She was able to state that she had had surgery, but still required cues for the fact that she had brain surgery. She did spontaneously remember that she had an aneurysm. She was asked to write in a memory book, and she required prompts and cues to know that she had had brain surgery. She continued to have left cranial nerve VI palsy. She did present difficulties with attention and concentration. Dr. Doe, Cardiology, saw the patient and recommended Coreg and Prinivil in order to optimize cardiac function. She was encouraged to wear an eye patch on her left eye in order to improve the diplopia. She did have complaints of headache during her stay, and these were relieved with Tylenol or Motrin. On MM/DD/YYYY, there appeared to be a decrease in mental status. She was confused, having difficulty processing information and emotionally labile. A CT was obtained and the official report revealed no change, no intracerebral hemorrhage. The patient did appear to be hypotensive and hydration was performed with IV. Her blood pressure went down to 96/64, and once it returned to 122/86, she appeared to respond appropriately at her baseline level. Dr. Doe saw the patient and recommended discontinuing and avoiding centrally-acting medications unless absolutely necessary. Therefore, Exelon and trazodone were discontinued. Dr. Doe also recommended an EEG, and the report was pending at discharge. Family was instructed to make an appointment with Dr. Doe, the patient’s primary care physician, within one month after discharge. They were also instructed to purchase a blood pressure monitor with a digital readout in order to take the patient’s blood pressure at home, twice a day. The patient did have a followup appointment with Dr. Doe on MM/DD/YYYY. The patient was able to ambulate throughout here with therapy, greater than 1000 feet. Per the psychology department, the patient had limited awareness of cognitive deficits and needs 24-hour supervision, no alcohol, no smoking, and no driving. They recommended neuropsychological testing if orientation improves. Speech language pathology recommended continued cognitive treatment on an outpatient basis. Speech language pathology report indicated the patient made little to no cognitive improvement during her rehabilitation stay. Per physical therapy department, as mentioned above, the patient could ambulate 500-2000 feet without an assistive device with standby assist to contact guard assist. She was able to go up and down 25 steps with one handrail and standby assist. They also stated that the patient continued to have deficits secondary to cognition and memory and requires supervision to standby assist for all mobility. They recommended discharge home with 24-hour supervision. Per occupational therapy, the patient progressed to supervised to standby assistance level with activities of daily living and functional mobility. She requires cues for problem solving, initiation, sequencing of tasks, and they recommended 24-hour supervision for safety. The patient was discharged home with sister in stable condition on MM/DD/YYYY. She was instructed to make a followup appointment within one month with her primary care physician. She was given prescriptions for her medications for one month.

1. Coreg 6.25 mg two tablets p.o. q.a.m. and one tablet p.o. q.p.m.
2. Aspirin 325 mg p.o. daily.
3. Pepcid 20 mg p.o. b.i.d.
4. Hydrochlorothiazide 25 mg one-half tablet p.o. daily.
5. Prinivil 20 mg p.o. daily.


DIET: Regular.

CONSULTS: Internal Medicine, Neurology, and Neuropsychology.

PHYSICAL EXAMINATION AT DISCHARGE: GENERAL: The patient is a (XX)-year-old female, pleasant, alert, cooperative, follows all commands appropriately, and had no overt pain behavior. There is a well-healed surgical site along the right posterior occipital area. HEART: Regular rate and rhythm. LUNGS: Clear to auscultation bilaterally. ABDOMEN: Positive bowel sounds, soft, and nontender. EXTREMITIES: No calf edema, thigh tenderness, or calf tenderness is noted. Distal pulses are intact. NEUROLOGICAL: She had continued severe short-term memory deficits. She could not recall 3 objects at 5 minutes. She had decreased visual acuity in the left eye in all fields. She had diplopia noted, particularly on the left. She had weakness in the left lateral gaze, although, not a complete VI nerve palsy. CEREBELLAR: Dysmetria with finger-to-nose testing, on the right; however, difficult to ascertain if this is related to diplopia versus ataxia. STRENGTH: Generally, 5/5 throughout in the upper and lower extremities with no focal weakness. No clonus at the ankles. There is a right-left confusion. Right pupil is 6-4 mm and left pupil is 5-3 mm. There is also a left ptosis.



FOLLOWUP APPOINTMENTS: The patient was instructed to call her primary care physician within one month to schedule a followup appointment. She will also follow up with Dr. Doe here in approximately 6 weeks. She should make followup appointments with Dr. Jane Doe as instructed.

Followup therapy is recommended on an outpatient basis. As mentioned above, the patient’s family was instructed to take the patient’s blood pressure twice a day and to hold Coreg if the systolic blood pressure is less than 130 or pulse is less than 60. They were also instructed to not give Prinivil if systolic blood pressure is less than 110.

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