Physiatric / Physiatry / Physical Medicine and Rehabilitation Medical Transcription Sample Report



HISTORY OF PRESENT ILLNESS:  The patient is a (XX)-year-old female who was the driver in a motor vehicle collision in car versus semi.  She was struck from behind and her car fishtailed and ended up under the tractor trailer.  The patient was found crashed into the truck with the wheel overlying her pelvis.  Thereafter, there was obviously a prolonged extrication for approximately 45 minutes.  Her GCS at the scene was 14.  The patient was transported by air to a hospital and intubated before her CT.  By CT and x-ray, the patient was found to have a left clavicular fracture, nondisplaced, a left pelvic iliac crest fracture, comminuted, a left midshaft tib-fib fracture, a left pelvic ring fracture, and a left sacral fracture.  The patient also had a perineal laceration.  Her hospital course was eventful for the transfusion of 1 unit of packed red blood cells and acquisition of an UTI for which she is being treated with Cipro.  There is no discharge summary available, but according to the nurse's report, she has been catheterized for very large volumes since discontinuation of her Foley.  Her hospital course was otherwise unremarkable.



SOCIAL HISTORY:  The patient lives with her mother in a 3-story house with a bathroom in the second floor.  No tobacco, alcohol or drugs.  

ACTIVITY RESTRICTIONS:  The patient is weightbearing as tolerated in her left upper extremity and toe-touch weightbearing in her left lower extremity.

MEDICATIONS:  Percocet 1 to 2 tablets p.o. q.4 h. p.r.n. pain, Colace 100 mg p.o. b.i.d. p.r.n., Fragmin 5000 units subcutaneously daily, iron 350 mg p.o. t.i.d. x1 month, Zofran p.r.n., and two remaining days of ciprofloxacin 500 mg p.o. q.12 h.

REVIEW OF SYSTEMS:  The patient complains of pain in her leg and across her clavicle.  No shortness of breath.  No dysuria.  The patient does have some diarrhea after fairly aggressive anticonstipation regimen.

VITAL SIGNS:  Temperature 97.6 degrees, pulse 86, respirations 16, and blood pressure 118/80.
GENERAL:  The patient is awake.
HEENT:  Pupils are equal, round, and reactive to light and accommodation.  Her extraocular muscles are intact.  Her oropharynx is clear.
HEART:  Regular rate and rhythm.  No murmur.
LUNGS:  Clear to auscultation bilaterally.  She has ecchymosis over her left clavicle, her abdomen, and her pelvis.
ABDOMEN:  The patient's belly is soft, nontender, and nondistended.  She has good bowel sounds.
EXTREMITIES:  She has multiple abrasions on her extremities.
MENTAL STATUS:  The patient is alert and oriented x4.  She is lucid and fluent.  Her speech is fluent and clear.  Her manual muscle testing is very difficult to assess secondary to pain with range of motion, but her right upper extremity and right lower extremity are grossly normal.  Her left lower extremity is in an immobilizing brace, but she has good capillary refill.  Her incision is clean, dry, and intact.  She appears to be neurovascularly intact.  Her left upper extremity is not repaired, but is quite tender.  She does not wish to move this secondary to pain.

ASSESSMENT AND PLAN:  The patient is a (XX)-year-old female, status post multiple trauma.
1.  Rehabilitation:  Toe-touch weightbearing, left lower extremity.  Weightbearing as tolerated, left upper extremity.  PT, OT, speech language pathology, therapeutic recreation, and psychology to see and treat.
2.  Deep venous thrombosis prophylaxis:  The patient is on Fragmin.  The patient is to have her Dopplers repeated.
3.  Gastrointestinal prophylaxis:  The patient is not on anything, but complains of systemic nausea.  We will start Pepcid 20 mg b.i.d.
4.  Bowel and bladder:  Overflow urinary incontinence.  We will place Foley and start Urecholine 12.5 mg p.o. t.i.d.
5.  Pain:  Not well controlled.  Start Oramorph 15 mg with Percocet for breakthrough and schedule before therapies.

DISPOSITION:  The patient will likely be discharged to home with any equipment and modifications that she needs.




1.  Left tibial-fibular fracture secondary to motorcycle accident.
2.  Left above-knee amputation.
3.  Phantom limb pain.

HOSPITAL COURSE:  The patient is a (XX)-year-old female who was involved in a motorcycle accident.  The patient was parked off the road, when a car skidded across and collided with her motorcycle.  Her Glasgow coma scale in the ER was 15.  The patient was noted there to have an open tibial-fibular fracture with near amputation of the lower extremity.  The patient was taken to the OR and knee disarticulation was performed on the same day.  This was revised to a left AKA subsequently.  The patient's head CT was negative.  Her hospital course was relatively uncomplicated, except for significant phantom limb pain, which was treated at the hospital with methadone and Vicodin.  The patient was functionally independent prior to admission.

1.  On admission, her FIM scores were min assist to supervision with ADLs.  On discharge, these were modified independent to complete independent.  On admission, she was min assist with bladder and bowel and modified independent on discharge.  For mobility, she was min assist on admission and modified independent on discharge.  For locomotion, she was total assist on admission and modified independent on discharge for walking and wheelchair locomotion.  Max assist for stairs.  Comprehension and expression FIM scores were supervision to modified independent and complete independence on discharge.  Social interaction, problem solving, and memory were at supervision to modified independent on admission and complete independence on discharge.  Her admission total FIM score was 84 and on discharge was 110.  The patient participated in PT, OT, and recreational therapies.  The patient was involved with preprosthetic training.
2.  Orthopedics:  The patient's above-knee amputation incision remained intact.  It was wrapped here with an Ace wrap.  She will require residual limb shrinker for further preprosthetic molding of her residual limb.
3.  Pain:  Her pain was addressed with Neurontin and methadone.  The Vicodin was discontinued at the patient’s request, and she remained stable on Tylenol and Ultram.
4.  DVT:  The patient had negative Dopplers and had been prophylaxed with Fragmin previously.  The Fragmin was discontinued on transfer to this facility, and she was monitored for signs and symptoms of DVT without any incident.
5.  Bowel and bladder:  The patient was started on Citrucel and Kondremul and these were discontinued, and she started Senna-S b.i.d. and Dulcolax suppository p.r.n. secondary to her pain being treated with narcotics.
6.  FEN:  The patient was on a regular diet, and there were no issues with this.

FOLLOWUP:  The patient is to see Dr. John Doe in 1 to 2 weeks and Dr. Jane Doe on MM/DD/YYYY at 3:30 p.m.  The patient is to go to the vascular lab for followup Dopplers.  The patient will be seen at the trauma clinic on MM/DD/YYYY at 11:30 a.m.

OUTPATIENT THERAPIES:  The patient will have outpatient therapies, physical therapy and occupational therapy.

DISCHARGE EQUIPMENT:  The patient is discharged with wheelchair, a rolling walker, and a prescription for handicap parking placard.

MEDICATIONS AT DISCHARGE:  Methadone 5 mg daily, Neurontin 100 mg q.8 h., Tylenol 650 mg q.6 h. p.r.n., Ultram 50 mg 1 to 2 p.o. q.6 h. p.r.n., Senna-S one p.o. b.i.d., and trazodone 50 mg p.o. at bedtime p.r.n.

REASON FOR ADMISSION:  Rehabilitation status post left hemiplegia secondary to brain abscess and craniotomy.

CHIEF COMPLAINT:  Paralyzed left side and difficulty with walking.

HISTORY OF PRESENT ILLNESS:  This is a (XX)-year-old female who is being readmitted to this facility.  Initial diagnosis was right frontal lobe brain abscess, status post craniotomy and excision.  The patient had a moderate left hemiparesis and had an impairment of mobility and activities of daily living.  The patient was admitted for intensive rehabilitation.  The patient came in with Dilantin and multiple medications.  The patient was taking Rocephin IV for continued abscess treatment along with penicillin G.  There was no evidence of metastatic brain tumor as initially thought at one time.  The patient was doing fairly well until MM/DD/YYYY, about 7 o'clock in the morning.  The patient became quite lethargic and was not arousable.  It was felt the patient had worsening of her neurological status, and the patient was subsequently transferred to the ER and was subsequently admitted.  The admitting diagnosis was possible cerebral hematoma, persistent brain abscess with encephalopathy, and seizure disorder.  Dr. John Doe was reconsulted.  The patient was placed on IV antibiotics again.  The patient completed the course of IV Rocephin and is now on oral Augmentin.  During the hospitalization, the patient developed Stevens-Johnson syndrome, likely secondary to Dilantin.  Dilantin was discontinued.  The patient had a severe skin reaction, which is now improving; involvement was mostly the upper extremities and the truncal areas.  The process spared the lower extremities for the most part.  The patient was seen by Dr. Jane Doe for neurosurgical consultation.  It was felt that the patient did not have a surgical lesion.  The patient was placed on Decadron, and as noted, IV antibiotics were continued.  The patient had a course of Famvir, Flagyl, and Diflucan.  All those medications were discontinued, and as noted, the patient is only on Augmentin at this time, by mouth.  It appears that the patient's left-sided weakness got much worse during the hospitalization with this event.  The patient remained seizure-free during the hospitalization.  Dr. Bradford Doe was consulted, and the patient was placed on Keppra.  Motor examination revealed fairly dense left hemiplegia.  Due to the recent worsening of mental status, which is now improving but with worsening of left hemiplegia, the patient has severe impairment of mobility and activities of daily living.  The patient requires intensive and comprehensive inpatient rehabilitation for her deficits and functional impairment.  Therefore, the patient was admitted to this facility for comprehensive inpatient rehabilitation.

PAST MEDICAL HISTORY:  Hypertension, seizure disorder, hypercholesterolemia, questionable history of coronary artery disease, history of breast cancer, melanoma, and hypothyroidism.

SOCIAL HISTORY:  The patient is married.  The patient lives in a two-story home with one step to enter and nine steps within.  All the bedrooms are upstairs, but there is a bathroom and a shower downstairs.

PREVIOUS LEVEL OF FUNCTION:  The patient was independent with ambulation and activities of daily living previous to hospitalization.  The patient was also working part-time two days a week.


REVIEW OF SYSTEMS:  The patient denies any headache, dizziness, blurry vision, nausea, vomiting, chest pain, shortness of breath, diarrhea or constipation.  The patient has a Foley catheter.  The patient is somewhat lethargic but answers questions appropriately.

GENERAL:  The patient is awake but mildly lethargic.  The patient complained of chest pain earlier today, which has now resolved.  There is moderate left neglect.
VITAL SIGNS:  Blood pressure 156/78, pulse 92, respirations 18, and temperature 98.6 degrees.
HEENT:  The head incision is clean and dry and well healed.  There are no staples.  Pupils are equal and reactive to light bilaterally; however, extraocular movement is impaired to the left side.  The patient has a right gaze preference, likely because of left neglect.  The intraoral cavity is slightly red and irritated but appears to be healing.
HEART:  S1 and S2, regular.
LUNGS:  Decreased breath sounds throughout but clear.
ABDOMEN:  Soft.  Good bowel sounds.  No tenderness.
EXTREMITIES:  There is no calf tenderness.  There is some minimal swelling of the left lower extremity.  Dorsalis pedis is faint bilaterally.
SKIN:  Both upper extremities showed peeling skin without any evidence of infection or active blisters.  Bilateral trunks and abdomen and the back area shows redness and resolving blisters and again skin is peeling/sloughing.  The facial area also shows slight sloughing.
NEUROMUSCULAR:  Right upper and lower extremity strength is good without focal deficits.  Left upper extremity strength is trace throughout.  The left lower extremity strength is trace proximally and zero distally.

FUNCTIONAL EVALUATION:  The patient requires maximal assistance with sit-to-stand transfers.  The patient requires moderate assistance for standing and is able to take a few steps with moderate assistance.  The patient requires maximal assistance with activities of daily living.  The patient has some definite cognitive deficit due to encephalopathy.


CONDITION ON ADMISSION:  Stable to undergo rehabilitation.

1.   Impairment, severe, mobility and activities of daily living and cognitive function and visual deficit.
2.   Right frontal brain abscess with a history of previous craniotomy and evacuation, about six weeks postoperative.
3.   Encephalopathy.
4.   Dense left hemiplegia.
5.   Left neglect.
6.   Mild dysphagia.
7.   Stevens-Johnson syndrome due to Dilantin.
8.   Seizure disorder.
9.   Hypertension.
10. Questionable history of coronary artery disease with chest pain syndrome.
11. Hypothyroidism.
12. Leukocytosis.
13. History of breast cancer.
14. History of melanoma.
15. Anemia.

1.   Minimal assistance to supervision for bed mobility, supervision for functional transfers, possibly minimal assistance for transfers depending on the recovery on the left side, minimal assistance for limited household level ambulation, pending left lower extremity improvement.
2.   Seizure-free status.
3.   Improvement of cognitive status.
4.   Resolution of skin condition/Stevens-Johnson syndrome.
5.   Medical management of hypertension.


PRESENT IMPAIRMENTS:  This patient has a dense left hemiplegia, which interferes with activities of daily living and mobility.  The patient's case is further complicated by the left neglect and some cognitive deficit.  The patient is on multiple precautions, including fall, seizure, and aspiration precautions.

MEDICAL AND REHABILITATION PLAN:  This patient will require intensive and comprehensive inpatient rehabilitation.  The patient will receive physiatric care.  The case was discussed with Dr. John Doe on the date of admission.  Dr. John Doe agreed to discontinue all other antibiotics, antifungal, and antiviral.  The patient will be on Augmentin 875 mg p.o. b.i.d. only for the next month.  The patient will continue with the Decadron, which will be tapered off slowly.  Other medications will be continued for her blood pressure and hypothyroidism.  Blood pressure will be monitored closely.  The patient's skin will be monitored closely for any infection or further deterioration.

The patient will be placed on multiple precautions, including aspiration, seizure, and fall precautions.  Appropriate labs will be checked.  EKG was checked earlier and there was no evidence of acute ST-T changes; however, CPK and troponin I will be checked in the morning.  Liver function tests, sedimentation rate, CBC, basic metabolic panel, and UA will also be checked.  The patient's husband was at bedside and the patient's current situation and status were discussed.  Foley catheter will be kept in for the time being.  The patient will receive 24-hour rehabilitation nursing care.  The patient will continue the Foley catheter for now, but eventually, Foley will be discontinued and bladder program will be established.  The patient should be free of incontinence or retention.  Bowel program will also be established to prevent constipation and also to prevent any kind of incontinence.  Skin will be monitored and managed on a daily basis to make sure there is no secondary infection.  The patient and the family will be educated on medication management.  Vital signs will be monitored.  Part of the self-care activities including bathing will be emphasized.  The patient will receive interdisciplinary therapeutic interventions, including physical therapy and occupational therapy, social services, speech therapy, respiratory therapy, clinical psychology, and dietary services.  Team conferences and frequent team meetings will be held weekly to optimize and coordinate the patient's care.

Physical Therapy will work with the patient on mobilization skills, including bed mobility, transfer, pregait, and gait training.  The patient will be weightbearing as tolerated.  The patient will be placed on fall precautions.  Occupational Therapy will work with the patient on self-care skills, including feeding, grooming, upper body dressing, lower body dressing, functional transfers, and bathroom skills.  Left upper extremity strengthening, range of motion, and high-level ADL will be incorporated.  Visual-perceptual motor skills will also be incorporated.  Speech Therapy will work with the patient on cognition, swallow, and communication.  The patient has encephalopathy and has poor cognition.  Social Service will work with the patient and the husband on appropriate discharge planning.  It is expected that the patient will go home.  However, there is a barrier at home with nine steps inside the house.  Respiratory Therapy will monitor oxygen saturation and administer oxygen as needed.  Deep breathing will be encouraged.  Clinical Psychology will work with the patient on possible depression and also for cognitive and adjustment difficulties.  Dietary will work with patient on appropriate diet.  The patient is on mechanical soft diet with thin liquids and also the patient will require supervision and assistance.  The patient is on aspiration precautions.

REHABILITATION PROGNOSIS:  The patient has a reasonably good prognosis at this time.  Depending on the patient's neurological recovery on the left side, the patient's functional status will change.  However, the patient is expected to go home within the given length of time.