SUBJECTIVE: The patient reports no complaints. He is tolerating therapy well. He does not have any burning on urination and has minimal discomfort in his hips.
OBJECTIVE:
General: The patient is a well-developed, well-nourished male, in no apparent distress.
Vital Signs: Temperature 98.8 degrees, pulse 62, respirations 18, and blood pressure 136/58.
HEENT: Head is normocephalic.
Neck: Supple to palpation.
Lungs: Clear to auscultation.
Heart: Regular rate and rhythm with a grade 2/6 systolic ejection murmur.
Extremities: Examination of the extremities showed good peripheral pulses and is normal in regards to color, tone, and circulation. The wound on the patient’s hip is well healed without any sign of infection or skin breakdown.
FUNCTIONAL STATUS: Functional skills are at a supervised level with transfers and mobility skills. He is able to ambulate little greater than 250 feet with the use of a front-wheel walker. He still requires some contact guard assistance, particularly with high-level mobility skills. His self-care skills still showed some impairment with his memory; however, he does demonstrate approximately 80% accuracy. He is at a supervised level with his bathroom skills.
LABORATORY DATA: The patient’s urine grew out Enterococcus faecalis sensitive to ciprofloxacin.
ASSESSMENT:
1. Status post femur fracture, status post total hip replacement.
2. Urinary tract infection, resolving.
3. History of carcinoma of the prostate.
PLAN: We will continue the current treatment program in preparation for discharge to home today or tomorrow depending on family support, and this will be discussed in team conference today.
SUBJECTIVE: The patient states that he slept very well and feels quite refreshed today.
OBJECTIVE:
Vital Signs: Temperature 97.2 degrees, pulse 66, respirations 20, and blood pressure 132/62.
HEENT: Head is normocephalic.
Neck: Supple to palpation.
Lungs: Clear to auscultation.
Extremities: The wound on the patient’s hip is well healed without any sign of infection or skin breakdown. Staples and sutures are ready for removal.
FUNCTIONAL STATUS: Functionally, the patient is able to transfer and ambulate 100 feet x2 with the use of a front-wheel walker. He is able to begin ascending and descending steps but still is not competent at that. His sit-to-stand transfers require minimal assistance at this point. Bathroom skills are at a minimal assistance level. Staples and sutures on the patient’s leg are ready for removal and support stocking elastic band at the top appears to be too tight for the patient, and support stockings will be discontinued.
ASSESSMENT:
1. Status post right total hip arthroplasty.
2. Osteoarthritis of the right hip.
PLAN: We will continue with current treatment program with plans for the patient to be discharged to home this week.
SUBJECTIVE: The patient has no complaints. He is tolerating therapy well. He showed improved concentration, memory, and strength.
OBJECTIVE:
Vital Signs: Temperature 98.2 degrees, pulse 90, respirations 18, and blood pressure 138/88.
HEENT: Head is normocephalic.
Neck: Supple to palpation.
Lungs: Clear to auscultation.
LABORATORY DATA: The patient’s blood sugars are still running slightly elevated.
FUNCTIONAL STATUS: The patient shows improved balance and some passive movement is emerging from his right upper and lower extremity. Functional transfers are still at moderate assistance level, and he requires maximal assistance for lower body dressing. He is at a supervised level for upper body dressing skills. Oral motor control is still sluggish, and the patient is somewhat unsafe with his swallow, even with chin tucking technique.
ASSESSMENT:
1. Cerebrovascular accident.
2. Dysphagia.
3. Dysarthria.
4. Right hemiparesis.
PLAN: We will continue with the current treatment program. The patient will begin training on tall kneeling techniques.
