Traumatic Brain Injury/General Rehab
Physician History and Physical Evaluation
History and Physical Exam Date:
Date of Injury/Onset:
Primary Rehab Diagnosis:
Etiologic Diagnosis:
Referring MD:
Primary Care MD:
History of Present Illness:
The patient was seen and examined with
Co Morbidities and Related Diagnoses:
Diagnostic Tests:
Past Medical History:
Past Surgical History:
Family History:
Current Diet:
Allergies:
Medications:
Home medications:
Social History:
Marital Status: Primary Language Spoken:
Previous employment status:
Tobacco Use:
Alcohol Use:
Drug Use:
Level of Education:
Current Living Situation:
Discharge Living Situation:
Caregiver/supervision:
Review of Systems:
Functional History:
Premorbid functional history was abnormal in the following areas:
ADLs:
MOBILITY:
BLADDER:
BOWEL:
COMMUNICATION:
COGNITION:
Current Status:
Physical Exam:
Vital signs:
TEMP:
PULSE:
O2 SAT:
BLOOD PRESSURE:
RESPIRATORY RATE:
HEENT: Atraumatic, normocephalic, PERRLA.
NECK: Nontender, full range of motion, no lymphadenopathy. Negative thyroid exam.
LUNGS: Clear to auscultation, no rales, rhonchi or wheezes.
CARDIAC: Regular rate and rhythm
ABDOMEN: Positive bowel sounds, nontender, nondistended. No appreciable organomegaly or masses.
EXTREMITIES: See neurological exam
RANGE OF MOTION/CONTRACTURES: Full range of motion in all joints all extremities. Passive range of motion within normal limits bilateral upper and lower extremities. No contractures.
SKIN: Clear. Capillary refill > 2 seconds all extremities. Normal hair at distal extremities.
VASCULAR: Carotid, radial, femoral, DP pulses +2 and equal bilaterally.
Neurological Exam:
Cooperation with exam: The patient was cooperative with the neurological exam.
Orientation:
Rancho Level:
Recent and Remote Memory:
Attention Span and Concentration:
Communication (comprehension & expression):
Fund of Knowledge (e.g. awareness of current events):
Cranial Nerves: Cranial nerves II-XII intact.
Sensation:
Light Touch:
Pinprick:
Proprioception:
Pain: The patient has the following pain issues:
Babinski:
Cerebellar:
Motor Strength and Control:
Right Upper Extremity:
Left Upper Extremity:
Right Lower Extremity:
Left Lower Extremity:
Deep Tendon Reflexes:
Tone:
Lab Findings:
Impression and Plan:
1. Primary Diagnosis: Left frontal intraparenchymal hemorrhage with R hemiplegia. Since the patient fell on 8/2/06 and became symptomatic the next day, this could be secondary to fall rather than HTN.
2. Secondary Diagnosis: R hemiplegia, aphasia, hypertension, hypothyroidism, atrial fibrillation
3. Neuro: as above. No history of seizure. Monitor call light use and unsafe transfers. PT, OT and ST for improved ADL, cognitive function, communication, bed mobility transfers, wheelchair mobility, pregait and gait as appropriate, and energy conservation techniques.
4. Respiratory: Now on 1L O2 nasal canula. Will wean down O2.
5. DVT prophylaxis: SCDs and TEDs, OOB as tolerated.
6. Mood/behavior: Currently non-agitated. Monitor.
7. Pain: Tylenol prn. Oxycodone for severe pain.
8. GI Prophylaxis: Protonix 40mg po daily
9. Sleep: Ambien qhs prn. Follow sleep/wake chart.
10. B/B: d/c foley and follow I +O's and PVRs, BTP with Colace and dulcolax. Check UA, Urine C+S.
11. GI/FEN: Cardiac, low salt diet with thin liquids.
12. Atrial fibrillation: Continue labetalol for rate control. Hold coumadin due to intracranial bleed. Monitor INR until normal.
13. HTN: Well controlled. Continue labetalol to keep SBP < 150.
14. Hypothyroidism: Continue levothyroxine.
15. Arthritis: Pain management.