Rehab Discharge Summary Medical Transcription Sample Report
1. Lumbar spinal stenosis, status post decompression and stabilization surgery.
5. Urinary retention.
DISCHARGE DISPOSITION: Skilled nursing facility.
1. Dr. John Doe, Urology.
2. Dr. Jane Doe, Internal Medicine.
3. Neurosurgical service.
1. Synthroid 100 mcg every day.
2. Protonix 40 mg every day.
3. Neurontin 300 mg 3 times a day.
4. Atenolol 50 mg by mouth every day.
5. Lasix 20 mg by mouth every morning.
6. Potassium chloride 10 mEq by mouth every morning.
7. Diovan 80 mg by mouth every day.
8. Ferrous sulfate 325 mg by mouth twice a day with meals.
9. Flomax 0.4 by mouth twice a day.
10. Urecholine 25 mg by mouth 3 times a day.
11. Starlix 60 mg by mouth before meals.
12. Tylenol 1000 mg by mouth at 8 a.m. and 12 p.m. and as needed. Overall dose not to exceed 4 grams in 24 hours.
13. Antacid of choice.
14. Laxative of choice.
15. Sliding scale insulin.
16. She is also to have ChloraPrep to the lumbar incision site every day. Leave incision otherwise open to air.
RECOMMENDATIONS: Ongoing skilled nursing, PT and OT for ADLs, self-care, mobility, transfer training and incisional monitoring.
HISTORY OF PRESENT ILLNESS: The patient is a very pleasant (XX)-year-old female with significant lumbar stenosis and disk displacement who was admitted to the hospital with intractable neurogenic claudication and disk herniation. The patient underwent lumbar decompression and stabilization surgery. The patient’s course was notable for persistent functional impairments for which the patient was admitted to the acute inpatient rehabilitation unit.
1. Lumbar stenosis with disk disease and decompression surgery. The surgical incisional site actually showed good evidence of healing, though slight drainage there. However, we continued with ChloraPrep at that site, and there was no drainage at the time of discharge. She did have ongoing issues of weakness in her lower extremities, which may have been, in part, related to neurogenic issues as well as from decreased mobility from chronic pain issues, as she had been less mobile in the last 9 months.
2. DVT prophylaxis. She was maintained on SCDs and TED hose and did not have any evidence of asymmetrical edema.
3. GI prophylaxis. She was maintained on Protonix.
4. Hypertension. Her systolic blood pressure did tend to range a little high, but by the time of discharge, it was in a range that was closer to 100-120/60-80.
5. Urinary retention. She had some issues with high postvoid residuals for which she was on Flomax as well as Urecholine; these dosages were adjusted. We also asked for urology consult, and she will need to follow up with Urology as an outpatient for more formal urodynamic testing.
6. Hypothyroidism was stable on Synthroid.
7. Diabetes. She was on Starlix as well as sliding scale insulin.
FUNCTIONAL STATUS: Concerning the patient’s functional status, she still had problems with bed mobility, but she was standby assistance to minimal assistance for sit-to-stand, and her functional status fluctuated a lot based on her fatigue level. She was able to ambulate 70 feet with a rolling walker and standby assistance. She was minimal assistance to contact guard assistance with ADLs and transfers. A family conference was held given the fact that she had impairments with her ongoing mobility and ADL issues. We did recommend ongoing skilled therapies and 24/7 assist.
1. Cerebrovascular accident with residual right-sided weakness.
3. Atrial fibrillation.
6. History of pulmonary embolism.
7. Proteus urinary tract infection and Enterococcus urinary tract infection, both sensitive to Cipro.
1. Aspirin 81 mg p.o. daily.
2. Fragmin 5000 units subcutaneous every day x2 months.
3. Synthroid 50 mcg p.o. q a.m.
4. Antivert 12.5 mg p.o. q.6h.
5. Amiodarone 200 mg p.o. daily.
6. Folic acid 1 mg p.o. daily.
7. Norvasc 5 mg p.o. daily.
8. Antacid of choice.
9. Laxative of choice.
10. Tylenol PM.
11. Nitroglycerin 0.4 mg sublingual p.r.n. chest pain, may repeat x2. To call the physician at the nursing home if the patient does have any chest pain.
ALLERGIES: She has no known drug allergies.
DISCHARGE DISPOSITION: Skilled nursing facility.
RECOMMENDATIONS: Skilled OT, PT and speech therapy for ongoing stroke rehabilitation therapy.
HISTORY OF PRESENT ILLNESS: The patient is an (XX)-year-old female who was admitted to the hospital with new onset right-sided weakness. She was diagnosed with an acute cerebrovascular accident. Her MRI showed low attenuation of right occipital lobe lesion, probably subacute infarct. She was admitted to the acute inpatient rehab unit due to persistent functional impairment.
1. CVA with right hemiparesis. Her blood pressure was under good control. She was on aspirin for stroke prophylaxis. Blood pressure was around 110 to 120 over 70 to 80.
2. Hypertension. She was stable on her blood pressure medication, as noted above.
3. DVT prophylaxis. Given the fact that she had significant weakness on that side, she was only ambulating 15 feet with a rolling walker, with mod assist. I am going to recommend her having ongoing DVT prophylaxis with Fragmin for another two months.
4. Atrial fibrillation. Due to the fact that she was felt not to be a good candidate for any further anticoagulation therapy, she was rate controlled with amiodarone and her heart rate ranged in the 88 per minute range.
5. Hypothyroidism. She was stable on Synthroid.
6. History of PE. As noted, she did have a history of this. She was maintained on Fragmin and we do recommend another two months of Fragmin for her.
FUNCTIONAL STATUS: At the time of discharge, she was functioning at the following level. She was min to mod assist for transfers. She was able to propel her wheelchair 50 to 60 feet. She was making progress, a little slow with edge of bed dressing, with min assist for lower extremity. She required cueing for right upper extremity positioning. She was able to ambulate 75 feet with min assist to contact guard assist with AFO in place. She had impaired attention. She was motivated, participated fairly well in therapies, but her level of function was still fairly impaired and we felt that she was going to continue to need a significant amount of physical assistance and as such was discharged to a skilled nursing facility, given family resources at home to provide home care for her was not available. The patient therefore was discharged to a skilled nursing facility.
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