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Rehab Consultation Medical Transcription Sample Note / Example




HISTORY OF PRESENT ILLNESS:  The patient is a (XX)-year-old right-handed male without significant past medical history, who was admitted with chest pain, cognitive changes and slurred speech. His blood pressure was 121/47. Troponins were positive. CPK-MB fraction was positive. The patient did rule in for a myocardial infarction. CT scan of the brain demonstrated periventricular small vessel disease. A followup MRI examination revealed periventricular small vessel disease, atrophy and a left temporal infarct. Carotid studies were unremarkable. Echocardiogram was unremarkable, except for moderate mitral regurgitation. The patient was placed on aspirin and is now on heparin and Coumadin. His liver function tests have been elevated. Right upper quadrant ultrasound was negative. A videofluoroscopic swallowing study is pending. The patient was started on pureed diet with honey-thick liquids after a bedside speech and language pathology swallow evaluation. The patient denies any pain. He is not sleeping well. He has chronic insomnia and has been on Ambien 5 mg at bedtime for at least a couple of years. His appetite is good. He did fall 6 days prior to admission but declined transfer to the hospital after the paramedics evaluated him at his home.


PAST SURGICAL HISTORY:  Status post right cataract surgery and prostate surgery.


MEDICATIONS:  Heparin infusion, Lopressor 25 mg b.i.d., lisinopril 2.5 mg daily, Ecotrin 325 mg daily, Coumadin 5 mg and Xenaderm b.i.d.

MEDICATIONS PRIOR TO ADMISSION:  Ambien 5 mg at bedtime p.r.n.

DIET:  Pureed with honey-thick liquids. He is receiving D5 half normal saline at 60 mL/hour.

FUNCTIONAL STATUS:  The patient requires mild to maximal assistance for self-care. He requires moderate assistance for bed mobility and transfers. He is ambulating 20 feet with minimal assistance on a rolling walker. He was independent with a rolling walker prior to admission. He was not driving.

SOCIAL HISTORY:  The patient is a widower. He has 3 children.  The patient lives alone with 2 steps to the entrance. He was a 2-pack-per-day smoker for 30 years. He quit 20 years ago. He drinks occasionally. He was made DNR during this hospital admission.

FAMILY HISTORY:  Noncontributory.

REVIEW OF SYSTEMS:  Per the HPI and PMH. Benign prostatic hypertrophy. Chronic insomnia. He wears glasses. No glaucoma. No hearing difficulties.

VITAL SIGNS:  Temperature 97.6, pulse 68, respirations 22, blood pressure 110/42, and oxygen saturation is 97% on 2 liters of oxygen. Height 5 feet 8 inches, weight 158 pounds, and BMI is 24.
GENERAL APPEARANCE:  Well-developed, well-nourished gentleman, in no acute distress. His affect was normal.
NECK:  There were no carotid bruits.
LUNGS:  Clear to auscultation and percussion.
HEART:  Regular rate and rhythm.
ABDOMEN:  Soft. Bowel sounds are positive. Nontender and nondistended.
EXTREMITIES:  No clubbing, cyanosis or edema. No calf erythema, warmth or tenderness. Peripheral pulses were strong and symmetrical. Passive range of motion was within functional limits throughout.
NEUROMUSCULAR:  The patient was alert and oriented x3. Immediate recall was 3/3 and 3/3 after 5 minutes. His speech was fluent with a moderate to severe dysarthria. Naming and repetition were intact. Basic problem solving and reasoning were intact. Attention and concentration were intact. Visual fields were full. There was a loss of left nasolabial fold. Hearing was intact to whisper bilaterally. Shoulder shrug was diminished on the right. His tongue protruded in the midline with good lateral movement. Motor: There was normal tone in all 4 extremities. No atrophy was noted. Strength was normal in the left upper and lower extremities. Strength was normal in the right lower extremity, except for 3/5 to 4/5 hip strength. He did have a pronator drift on the right. Right upper extremity strength was 5/5 proximally and 4/5 distally. Muscle stretch reflexes, absent ankle jerks and knee jerks bilaterally. Toe response was downgoing on the left and equivocal on the right. Coordination intact on the left, somewhat ataxic on the right. Sensory: Localization was intact. He did not extinguish to double simultaneous stimulation. Gait not tested at this time.

LABORATORY DATA:  Hemoglobin 11.6, white blood cell count 12,700, and platelet count 392,000. ESR was 49. INR 1.14 and PTT 34.6. Sodium 142, potassium 3.8, chloride 102, bicarbonate 24, BUN 18, creatinine 1.2, glucose 117, calcium 7.7, albumin 2.7, total protein 5.8, AST elevated at 69, ALT 52, alkaline phosphatase 64 and total bilirubin elevated at 1.4. TSH was normal at 2.08. Cholesterol 101, HDL 26, LDL 54 and triglycerides 94. Urine culture was negative. MRSA screen was negative.

1.  Left cerebrovascular accident.
2.  Right hemiparesis, dysarthria and dysphagia.
3.  Impaired mobility and self-care.
4.  Coronary artery disease, status post myocardial infarction.
5.  Moderate mitral regurgitation.
6.  Dyslipidemia with low HDL.
7.  Leukocytosis.
8.  Benign prostatic hypertrophy.
9.  Chronic insomnia.

RECOMMENDATIONS:  Physical, occupational and speech therapies should continue. The patient is appropriate for rehabilitation when he is stable. The patient may require 24-hour supervision at home. His bowels needed to be watched. His Ambien should be resumed. He should receive Tylenol as needed for general aches and pains.

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