ESTIMATED LENGTH OF STAY: Three and a half weeks.

HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old male with a history of multiple medical comorbidities who presented to an outside hospital with approximately a 9-day history of abdominal pain. He was diagnosed with diverticulitis with associated abscess. He underwent surgical draining with right colectomy and a partial ileum resection.

His hospital course was notable for persistent dependence on mechanical ventilator, requiring tracheostomy tube placement, abnormal elevated LFTs, DVTs in bilateral lower extremities and one upper extremity, acute renal failure, anemia, sepsis and Clostridium difficile colitis. He had a Greenfield filter placed and was also started on anticoagulation therapy due to DVT in his upper extremity.

He was transferred to this hospital where he was treated for postacute care and mechanical ventilator weaning. Since his hospitalization here, he was weaned from the ventilator and is currently decannulated. He has persistent impairments, including a right residual hemiparesis from his prior cerebrovascular accident and global weakness and poor endurance due to medical deconditioning from his acute hospital course and medical deconditioning.

Additionally, he has anemia with a recent H&H of 7.5 and 21 and has an abdominal and right groin wound as well as some redness of a stage I decubitus on his sacral area, as well as ongoing issues with hypertension.

ALLERGIES: He is allergic to Betadine and tape.

CURRENT MEDICATIONS: Include albuterol and Atrovent hand-held nebulizers, metoprolol, Flagyl, Prevacid, Fragmin and SAF-Gel to the wounds.

PAST MEDICAL AND SURGICAL HISTORY: Hypertension, coronary artery disease, status post coronary artery bypass graft, COPD, benign prostatic hypertrophy, status post TURP, history of peptic ulcer disease, status post Billroth I, history of pancreatitis, hyperlipidemia, status post cholecystectomy, history of inguinal hernia repair and history of splenectomy. He has a history of skin cancer.

FAMILY HISTORY: Noncontributory.

REVIEW OF SYSTEMS: The patient is tired. He does complain of diarrhea. He denies any headaches, dizziness or blurred vision. He denies any nausea, vomiting or constipation. He denies any chest pain or shortness of breath. He denies any fevers, chills or sweats. He is incontinent of bladder. Does have some diarrhea with occasional incontinence of this. He does have residual right-sided weakness and reddened area on his backside as well as wounds on his abdomen and groin. He has a nonproductive cough.

SOCIAL AND FUNCTIONAL HISTORY: He was independent prior to his current hospitalization. He is at this point planing on selling his home. He is aware that he may need further convalescence, and if so, he intends to go to a nursing home.

PHYSICAL EXAMINATION: VITAL SIGNS: Blood pressure is 140/66, temperature is 97.8 degrees, heart rate 78, respirations 22, height is 5 feet 7 inches and weight is 165-1/2 pounds. GENERAL: He is a pleasant, elderly male, in no acute distress. HEENT: Pupils are equal, round and reactive to light. EOMs are intact. He does have arcus senilis. Oropharynx is moist and pink. His dentition actually is in fairly good shape. NECK: Supple. No bruits. LUNGS: He does have a nonproductive cough. Lungs are otherwise clear to auscultation. No rales, wheezes or rhonchi. CARDIOVASCULAR: Notable for regular rate and rhythm without any murmurs, rubs or gallops. ABDOMEN: Soft, nontender and nondistended with normoactive bowel sounds. He does have an abdominal wound measuring 4.5 x 1.5 cm with approximately 1 cm depth. The wound itself has got beefy, red granulation tissue without any significant drainage. On his right groin, he has also another wound approximately 4 x 2 x 1 cm in depth, also with good granulation tissue on the wound bed and no significant drainage. SKIN: Of note, his skin has significant actinic keratosis over the scalp and face. He also has a fairly large seborrheic keratosis over his left upper arm. EXTREMITIES: No joint pain, deformity, range of motion impairment or laxity with the exception that he has external rotation of his right hip. We think it is, at least in part, related to some tightness in his external rotators on that side. He has decreased range of motion, which is at least in part related to decreased strength on his right foot. We are able to get him to range to neutral for ankle dorsiflexion. NEUROLOGIC: He is awake, alert and oriented x4. Speech is fluent and intelligible. His fund of knowledge is intact. His short-term and long-term memory is intact. Sensation is intact. He does have a trace to 1+ edema of his right ankle and foot. Motor strength is notable for 4+ to 5-/5 strength on the left side with proximal greater than distal weakness. He does not get full range of motion for shoulder abduction on that right side, and he has 4/5 to 4-/5 for deltoids, 4+ to 5- distally in that right upper extremity. For right hip flexor, he is 4-/5. Quadriceps, 3+ to 4-/5. He has very minimal resistance distally for his ankle dorsiflexion and plantarflexion, extensor hallucis longus. Gait is not tested.

IMPRESSION AND PLAN: The patient is (XX)-year-old male with multiple medical comorbidities and is currently medically deconditioned with residual right hemiparesis due to remote cerebrovascular accident but with significant medical deconditioning following a catastrophic illness.
1. Medical deconditioning. Engage OT, PT, TR.
2. Pulmonary, status post respiratory failure. His tracheostomy stoma is healing well. We will continue with hand-held nebulizers q.4 hours. Also, to consider cardiopulmonary rehab for endurance training and strengthening.
3. Cardiovascular and hypertension. He does have a history of coronary artery disease, status post coronary artery bypass graft. We will continue with metoprolol, monitor blood pressure and cardiac response to therapies.
4. Deep venous thrombosis, status post Greenfield filter placement. We will continue with treatment dosing of Fragmin and monitor. Plan to get bilateral knee-high TED hose.
5. Infectious disease. The patient initially with an abscess. Status post 42 days of antibiotics. Did have recent Clostridium difficile colitis. His most recent stool culture, however, was negative. We will continue with additional 5 days of Flagyl. We will monitor bowels. We may need to get a followup Clostridium difficile toxin evaluation on his stools depending on his amount of diarrhea.
6. Anemia. We will check followup CBC today. We may need to transfuse depending on how low he goes, and we will monitor for signs and symptoms of anemia at rest.
7. Wounds. Currently looks clean with good evidence of granulation tissue. We plan to ask wound care nurse to consult, and we will continue SAF-Gel for now.
8. Nutrition. We will continue with a regular diet, mechanical, soft, with thin liquids. We will check albumin and prealbumin.
9. Skin, actinic keratosis, history of skin cancer. We think he can follow up as an outpatient. We will watch for this so as to see that he does not have any abnormal skin, that is more concerning than the actinic keratosis.
10. Mood. Stable.
11. Disposition. We think he has an intact plan for domestic disposition, eventually, if not in the short term.

CODE STATUS. Full.

GOALS. The goals are for him to be at a modified independent level for ADLs and self-care. Probably will need wheelchair for long distance mobility. Cognitively, we think he is going to be intact, will not require supervision or cognitive assistance from rehab standpoint.

SUBJECTIVE: The patient states that his weekend went well. In particular, he states that his therapeutic pass/community reentry pass, though trying, was quite an eye-opening experience. He states that the experience was good for him.

OBJECTIVE: Temperature 99.0 degrees, pulse 88, respirations 20, and blood pressure 122/58. The head and neck examination was unremarkable. A Miami J collar was worn. The patient states he is not prepared to wear a soft cervical collar because it is not fitting well. He is waiting for a Philadelphia collar. Heart and lung examinations were within normal limits, except for a paradoxical pattern of respiration. The abdomen was soft, nontender, with active bowel sounds. There was no guarding or rebound tenderness. Thigh-high Ace wraps and TED hose were in place. The patient is wearing Stryker boots to pad his heels.

ASSESSMENT AND PLAN:
1. Rehabilitation: The patient continues to participate fully in all therapy sessions. A therapeutic pass yesterday was quite instructive for him. A team conference will be held tomorrow to review his functional goals and progress. Continue comprehensive inpatient rehabilitation.
2. Spine stability: Stable with soft cervical collar, though the patient continues to use a Miami J collar. Awaiting the Philadelphia collar.
3. Pain: Very little, if any, complaints except for occasional shoulder discomfort. Continue myofascial technique to the tight muscle groups in the upper trapezius muscles. Continue pain medications as written.
4. Bowel/bladder management: We will discuss this further during team conference. Working towards a regulated program. The patient and his family are involved with this.
5. Elevated temperature: Continues to fluctuate though a general trend of improvement is noted. The patient continues to receive ciprofloxacin for a urinary tract infection.
6. Left common femoral deep venous thrombosis: The INR today was 1.8. We will continue the Coumadin 7.5 mg daily and recheck the INR tomorrow. We hope to see a pattern and adjust the Coumadin accordingly.
7. Stage III sacral decubitus ulcer: Continues to heal with the electrical stimulation and nutritional supplements. We will evaluate this further during skin rounds tomorrow. We will likely continue the current plan of care.

Physical Medicine and Rehab SOAP Note Sample Report #2

SUBJECTIVE: The patient is without complaints today. However, he would nod off at times during the bedside evaluation. His father was at the bedside as well.

OBJECTIVE: Temperature 98.2, pulse 86, respirations 18, and blood pressure 92/52. Intermittent catheterization volume recorded, so far today, was 180 mL. The patient had a bowel movement earlier today. Head and neck examination showed the patient closing his eyes and nearly falling asleep one occasion. However, pupils are equal, round, and reactive to light. A Miami J collar was in place. Heart and lung examinations were within normal limits, except for a paradoxical pattern of respiration. The abdomen was soft and nontender with active bowel sounds. An abdominal binder was worn. The sacral dressing was intact. There was no lower extremity edema.

ASSESSMENT AND PLAN:
1. Rehabilitation: The patient is participating fully with encouragement in therapies. Discussions about spinal cord injury have been started. Continue comprehensive inpatient rehabilitation evaluation and treatment. Continue the prednisone taper.
2. Spine stability: Stable with Miami J collar. Continue present management.
3. Orthopedic: Surgical wounds are healing well. Continue spine precautions. The patient is scheduled for orthopedic followup next week.
4. Pain: Under good control. Perhaps, the patient may be able to be weaned from some of the medications as he is easily falling asleep. However, this could also be tiredness because of his decreased endurance.
5. Stage III sacral decubitus ulcer: Stable. The patient’s father again asked whether he could have a KinAir bed. He was told that the AccuMax overlay is appropriate for the patient and that his skin is healing. Continue wound care as written.
6. Pulmonary: Stable. Continue to work on improving the pulmonary status and diaphragm strength.
7. Neuropathic pain in the lower extremities: Reported more so in the left foot. The patient would like to hold off on adding Elavil to his treatment plan at this time. He will continue to use the Neurontin. The patient is aware that the Elavil will not interfere with the healing process.

Physical Medicine and Rehab SOAP Note Sample Report #3

SUBJECTIVE: The patient is without complaints. She states she was able to use the BiPAP overnight.

OBJECTIVE: Temperature 97.0 degrees, pulse 69, respirations 20, and blood pressure 113/48. The head and neck examination was unremarkable. The patient has a BiPAP machine at the bedside. A PICC line was noted in the right arm. A left exotropia was noted with dysconjugate gaze. Heart and lung examinations were within normal limits. The abdomen was soft, nontender, with active bowel sounds. There was a urostomy site as well as a colostomy site on the abdomen. There was also a PEG tube site. Knee-high TED hose was worn.

ASSESSMENT AND PLAN:
1. Rehabilitation: The patient continues to participate fully in all therapy sessions. She is showing fairly good endurance to be able to perform these activities. Continue comprehensive inpatient rehabilitation.
2. Hypertension: Good control. Continue present management. We may need to decrease some of the medications.
3. Lymphoma: Stable and followed by Dr. John Doe.
4. Depression: Slightly upbeat. Continue supportive therapy and medications as needed.
5. Bowel/bladder management: Manage with urostomy and colostomy. We will work towards a regulated program as well as teaching the family how to perform ostomy care.