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Physical Medicine and Rehab Discharge Summary Transcribed Sample Report



ADMISSION DIAGNOSIS:  Status post cerebrovascular accident with right hemiparesis, expressive aphasia, and slurred speech.

1.  Loss of strength, balance, mobility, endurance, and self-care.
2.  Hypertension.
3.  Internal carotid artery stenosis.
4.  Coronary artery disease with history of stent in the past.
5.  History of cerebrovascular accident in the past.
6.  History of smoking.

DISCHARGE ORDERS:  The patient was discharged home with a friend, with 24-hour supervision.  The patient is not to drive.  Supervision with ambulation and ADLs.  Diet is 2-gram sodium, low fat.

MEDICATIONS:  Aspirin 325 mg p.o. daily; Lipitor 40 mg p.o. nightly; Plavix 75 mg p.o. daily; Imdur 30 mg p.o. daily; Wellbutrin SR 150 mg p.o. b.i.d.; and Xanax 0.25 mg p.o. b.i.d. p.r.n.

FOLLOWUP:  With primary care physician.  Follow up with Dr. John Doe for possible carotid arteriogram.  Follow up with Dr. Jane Doe of Neurology.  Follow up with Dr. Bradford Doe.  Home care, physical therapy, occupational therapy evaluation, speech therapy, aide, psych social worker, durable medical equipment, single point cane.

BRIEF HISTORY:  This is a (XX)-year-old female with complaints of right-sided weakness and right facial droop.  Reportedly, the symptoms presented the day before.  She has a history and risk factors for stroke including hypertension, heart disease, previous cerebrovascular accidents, and smoking.  Initial CT scan of the brain was negative.  MRI imaging scan, MRA revealed left internal carotid artery occlusion, intermittent occlusion of the left middle cerebral artery.  The patient was admitted under the care of Dr. John Doe.  The patient was seen by Dr. Jane Doe for vascular evaluation.  CT angiogram revealed a completely occluded left common carotid.  She recommended carotid arteriogram in 2 to 3 weeks.  The patient's MRI scan showed an acute infarct of the left ganglion region.  The patient was transferred to rehab on Plavix and aspirin regimen to address her mobility and self-care.

MEDICAL COURSE:  While on rehab, the patient was managed medically by Dr. Jeff Doe.  While on rehab, the patient had developed some chest pains and Dr. Chris Doe was consulted.  She was monitored on telemetry and was felt to have symptoms of coronary artery disease.  The patient was cleared to continue her rehab and was recommended by Dr. Chris Doe to follow up with Cardiology for a stress test in the future.  During her remaining stay, she had no further episodes of chest pains.  She was treated for a urinary tract infection as well as for depression.  She was seen by Dr. Michael Doe of Neuropsych, who assessed the patient to be clinically depressed, exacerbated by her stroke.  However, the patient did not desire any psychotherapy and preferred to continue to address her depression with medications, and at the time of discharge, she was on Wellbutrin b.i.d. 150 mg.

LABORATORY VALUES:  Prior to discharge, her glucose was 92, BUN 14, creatinine 0.8, sodium 141, potassium 4.2, chloride 103, CO2 of 26, alkaline phosphatase 102, AST 14, ALT 36, total bilirubin 0.3, albumin 4, calcium 9.9, and total protein 6.8.  On MM/DD/YYYY, the cholesterol was 168, triglycerides 162, HDL 22, and LDL 117.  WBCs on MM/DD/YYYY were 8200, hemoglobin 12.6, hematocrit 36.8, and platelets 172,000.  RPR was nonreactive.

REHAB COURSE:  The patient was admitted and followed by physical therapy, occupational therapy, and speech.  During her course of rehab, she did have a home visit, did go on community reentry, and issues regarding her social situation were also addressed.  At the time of discharge, the patient, speech wise, was on a mechanical soft, chopped and thin diet.  Her oral motor was within normal limits, except for mild deficits with coordination.  She had mild oral movements and coordination deficits and moderate deficits with fluency of speech.  She was able to follow two-step commands within functional limits.  She had mild deficits with yes/no reliability, moderate deficits with evaluation of questions from a paragraph.  Mild deficits with complex conversation.  Her reading and comprehension were within functional limits.  Cognition was intact but she was noted not to fatigue easily.  She was oriented x3.  Her memory was within functional limits with immediate recent and remote memory.  She had mild problem solving deficits with thought organization, ability to reason, and judgment, and she was known to have a tendency towards depression.  However, her goals were met for the period that she was in rehab, and she was recommended further speech therapy.  Mobility wise, the patient was independent with bed mobility.  She was modified independent with transfers.  For ambulation, she was able to ambulate as much as 150 feet, supervision level, using a single-point cane.  She was supervision for negotiating 12 stairs/steps.  Functionally, she was feeding with independence, grooming and dressing upper body, dressing lower body, and her toileting was at modified independence.  Once again, for both physical therapy and occupational therapy, she was recommended continued therapy in the home with 24-hour supervision.  At the time of discharge, the patient was medically stable.  Laboratory values are provided above for the continuity of care.  Discharge instructions are outlined above.

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