Physiatry Consultation Sample Report
REASON FOR REFERRAL: Weakness.
HISTORY OF PRESENT ILLNESS: This is a patient who was admitted on (XX) for altered mental status, history of fall, evaluated in the emergency room and admitted for further workup. There is a history of hypertension, coronary artery disease, dementia, diabetes, and osteoarthritis.
PREMORBID FUNCTIONAL STATUS: Independent in ADL and ambulated without assistive device.
CURRENT FUNCTIONAL STATUS: Bed mobility, rolling with modified independent, and able to sit at the edge of the bed, and for a short time able to feed herself after a setup. Socially, lives with the daughter in a house.
MEDICATIONS: As per reconciliation.
ALLERGIES: PENICILLIN.
SOCIAL HISTORY: Denies smoking, drinking, or drugs.
FAMILY HISTORY: Noncontributory.
REVIEW OF SYSTEMS:
CONSTITUTIONAL: Just face weakness, tired.
CARDIOVASCULAR: No chest pain.
RESPIRATORY: No cold. No cough.
GASTROINTESTINAL: No nausea. No abdominal pain. No vomiting.
GENITOURINARY: No GU complaints.
NEURO-MUSCULOSKELETAL: Just weakness and arthritic pain.
GENERAL: Alert and obese.
VITAL SIGNS: Temperature 97.7, pulse 96, blood pressure 122/62, respirations 18.
HEENT: Normocephalic. Extraocular movements are intact. Pupils are equal and reactive to light and accommodation.
NECK: Supple. No JVD. No carotid bruits.
HEART: RSR. No murmur. No S3, no S4.
LUNGS: Clear to auscultation and percussion.
ABDOMEN: Soft. Bowel sounds plus. No guarding. No rigidity. No organomegaly.
NEURO-MUSCULOSKELETAL: Speech is functional. Hearing is functional. Cranial nerves are intact. Swallowing is functional with the current diet. Cognition impaired. Able to move both upper extremities with 3+/5 strength. Both lower extremities 3/5. Passive range of motion is within functional limits. Sensation is intact. Deep tendon reflexes are 2+.
SKIN: Intact.
LABORATORY DATA: The workup done here demonstrates hemoglobin 11.6, hematocrit 35.7, WBC 8.8, platelets 225,000. Chemistry shows sodium 147, potassium 3.9, chloride 108, carbon dioxide 28.5, glucose 144, troponin is less than 0.04.
ASSESSMENT:
- Debility.
- Altered mental status.
- Dementia.
- Osteoarthritis.
- Hypertension.
- Diabetes.
PLAN OF TREATMENT: Rehab potential is fair. Physiatry recommendations are to continue physical therapy. Continue fall precautions and short-term subacute rehab when medically stable.
