REASON FOR ADMISSION: Rehabilitation status post decompressive laminectomy.
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old Hispanic female with a history of progressive lower extremity weakness and chronic lower back pain, which has been going on for several weeks. The patient later began to develop pain in her lower extremities, left side greater than the right, and her condition progressed with numbness in her left lower extremity. The patient failed conservative treatment, and she was brought to an outside hospital where she underwent a multilevel lumbar laminectomy from L2 through L5.
The patient tolerated the surgery well, but postoperatively, she was still impaired with her self-care and mobility skills with limited ambulation and numbness in her lower extremities. It was felt that she would benefit from acute rehabilitation. She was then transferred here for continuation of her care and spinal rehabilitation program.
PAST MEDICAL HISTORY: As in HPI plus cancer of the breast, status post lumpectomy and removal of axillary nodes on the right.
SOCIAL HISTORY: The patient lives in a one-story home with no stairs or steps. She was previously independent with her activities of daily living and mobility skills. She does not smoke or chew tobacco or drink alcoholic beverages.
REVIEW OF SYSTEMS: The patient denies any nausea, vomiting, headache, diarrhea, constipation, fits, pains, seizures, psychiatric disorders or bowel or bladder dysfunction.
PHYSICAL EXAMINATION:
GENERAL: The patient is a well-developed, well-nourished female in no apparent distress.
VITAL SIGNS: Temperature 96.4 degrees, pulse 70, respirations 18, and blood pressure 146/62.
HEENT: Normocephalic. She has full ocular range of motion. Pupils are equal and reactive to light and accommodation.
NECK: Supple to palpation.
LUNGS: Clear to auscultation with diminished breath sounds.
HEART: S1 and S2 are present with no carotid bruits auscultated.
EXTREMITIES: Peripheral pulses are intact and good capillary return. Skin was essentially normal in regards to color, tone, and circulation. Lower extremities have no edema and Homans’ sign is absent.
BACK: Examination of the back shows spinal wound healing well without any sign of infection or skin breakdown and minimal serosanguineous drainage from the dressing.
PELVIC: Refused and would prefer to have this done with her PCP upon discharge.
RECTAL: Refused and would prefer to have this done with her PCP upon discharge.
BREASTS: Refused and would prefer to have this done with her PCP upon discharge.
FUNCTIONAL EVALUATION: The patient required minimal to moderate assistance with her self-care and mobility skills, and she is able to ambulate short distances with the use of a front-wheel walker and was limited secondary to resurgence of her back pain.
IMPRESSION:
1. Spinal stenosis, status post multilevel decompressive lumbar laminectomy.
2. Lumbar myelopathy.
3. History of breast cancer.
REHABILITATION GOALS: The patient being at a modified independent level with her activities of daily living and mobility skills.
ESTIMATED LENGTH OF STAY: Four to six days before returning to home.
PLAN: The patient is scheduled to undergo a course of physical and occupational therapy, dietary, and rehabilitation nursing with the goal of the patient being at a modified independent level with her activities of daily living and mobility skills. Physical therapy team will work with the patient on general mobilization skills, upper and lower body strengthening, pre-gait and gait training activities, and balance and coordination skills. Occupational therapy team will work with the patient on feeding, grooming, upper and lower body dressing skills, toilet-to-tub/shower transfers with and without the use of adaptive equipment. Dietary team will work with the patient on appropriate diet. Rehabilitation nursing team will work with the patient on bowel and bladder management program and appropriate taking of medications. All team members will be utilizing appropriate spinal precautions. Medical team will monitor the patient’s pain level and wound and will adjust therapies and medications as needed.
