PMBK Initial Consults

Admitting Diagnosis
[textarea name="variable_1" default="Generalized Weakness|Debility|Unsteady Gait"]
[select name="variable_1" value="
Initial Consultation|Follow up"]
[date name="variable_1" default="08-05-2022"]
[remark]content[/remark]
History of Presenting Illness:
[textarea name="variable_2" default="Admitted on * for rehabilitation in the setting of generalized weakness."]
[remark]content[/remark]
A consultation was requested to assess rehabilitation needs, develop a rehabilitation plan of care and address rehabilitation medicine diagnoses and their related issues.
[remark]content[/remark]
Allergies: [textarea name="variable_3" default="No Known Allergies"]
Past Surgical History: [textarea name="variable_4" default="Non Contributory"]
Family History: [textarea name="variable_5" default="Non Contributory"]
[remark]content[/remark]
Prior Functional History:
Before admission, patient was able to mobilize themselves independently
Previous Ambulation Devices:
[checkbox name="variable_1" value="No Device|Cane|Walker"][checkbox name="variable_2" value="Rollator|Wheelchair|Not Previously Ambulating"]
Patient's Prior Activities of Daily Living:
[checkbox name="variable_3" value="Dependent/Refused|Maximal Assistance|Moderate Assistance"][checkbox name="variable_4" value="Minimal Assistance|Setup but otherwise Independent|Independent"][checkbox name="variable_5" value="Assistance with Homemaking|Assistance with Grooming|"]
[remark]content[/remark]
Social History:
Residence - [textarea name="variable_6" default="Patient lives ** in a private home with * steps to enter. Denies ETOH/Tobacco usage. "]
[remark]content[/remark]
Pain Medication:
[textarea name="variable_7" default="Tylenol 650mg, Lidocaine Patch"]
[remark]content[/remark]
Medications:
[textarea name="variable_8" default="I have reviewed the patient's medications"]
[remark]content[/remark]
Review of Systems:
General
[checklist name="variable_1" value="Fatigue|Sleep Disturbances|Recent Falls"]
Neurological
[checklist name="variable_2" value="Dizziness|Syncope|Headache"][checklist name="variable_3" value="Coordination Changes|Weakness|Numbness"]
HEENT
[checklist name="variable_4" value="Vision Changes|Eye Pain|Ear Pain"][checklist name="variable_5" value="Dysphagia|Hearing Changes|Throat Pain"]
Cardiovascular
[checklist name="variable_6" value="Chest Pain|Palpitations"]
Respiratory
[checklist name="variable_7" value="Shortness of Breath|Wheezing|Cough"]
Gastrointestinal
[checklist name="variable_8" value="Nausea|Vomiting|Diarrhea"][checklist name="variable_9" value="Constipation|Abdominal Pain"]
Genitourinary
[checklist name="variable_10" value="Difficulty Urinating|Dysuria|Urinary Incontinence"]
Musculoskeletal
[checklist name="variable_11" value="Low Back Pain|Arthralgia|Myalgia"]
[remark]content[/remark]
Physical Exam:
Vital Signs - [textarea name="variable_9" default=""]
General - [textarea name="variable_10" default="No acute distress, Well developed, well-nourished"]
HEENT - [textarea name="variable_11" default="Head is normocephalic, atraumatic. No scleral icterus, no conjunctival pallor. "]
Neurological - [textarea name="variable_12" default="Alert and Oriented, Normal mood and affect, Cranial Nerves II-XII grossly intact. Follows commands. Sensation intact in b/l upper and lower extremity "]
Pulmonary - [textarea name="variable_13" default="Clear to auscultation B/L, no wheezing. Respiratory efforts within normal limits. Unlabored breathing."]
Cardiovascular - [textarea name="variable_14" default="Regular rate and rhythm, adequate perfusion"]
Gastrointestinal - [textarea name="variable_15" default="Abdomen soft, nontender, nondistended. No guarding."]
Musculoskeletal - [textarea name="variable_16" default="ROM in upper and lower extremities WFL. Demonstrates ability to move all extremities against gravity and with resistance."]
[remark]content[/remark]
Diagnostic Studies
[checkbox name="variable_6" value="I have reviewed this patient's lab results|No current labs at this time|I have reviewed this patient's diagnostic imaging"][checkbox name="variable_7" value="No diagnostic imaging to review at this time|"]
[remark]content[/remark]
Assessment:
[textarea name="variable_17" default=""]
[checkbox name="variable_8" value="R26.9-Repeated Falls|R13.12-Dysphagia,oropharyngeal phase|I69.328-Oth Speech/language deficits following CVA"][checkbox name="variable_9" value="M13.0-Polyarthritis, unspecified|M86.00-Osteomyelitis|M48.9-Spondylopathy, unspecified"][checkbox name="variable_10" value="M62.81-Muscle Weakness|M62.40-Contracture of muscle, unspecified|R53.81-Deconditioning"][checkbox name="variable_11" value="M79.2-Neuropathic pain|R26.2-Walking difficulty|R26.9-Unspecified abnormality of gait or mobility"][checkbox name="variable_12" value="Z73.6-Decreased ADL|Z74.09-Chairridden|Z74.1-Need assistance with personal care"]
Plan:
[textarea name="variable_18" default="Pain Regimen: Controlled on current pain regimen.Tylenol 650mg, Lidocaine Patch"]
Physical Therapy:
- Improve bed mobility and transfers through upper and lower body strengthening
- Progressive gait training and improve sitting/standing balance
- Encourage and train in breathing techniques to improve oxygenation during exertion
- Goal is to maximize strength and independence in ambulation.
Occupational Therapy:
- Train patient in self-care techniques and ADLs
- Employ strategies and evaluate for assistive devices to maximize independence at home
Speech Therapy:
- Improve deficits in speech/language and provide communicative strategies
- Cognition and memory evaluation with treatment of any deficits
- Evaluate dysphagia and deficits with feeding; treat dysphagia and manage diet recommendations as indicated
[remark]content[/remark]
Precautions: Fall - advised patient to use call bell for any assistance and to slowly progress from sit to stand