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Skilled Nursing Facility Discharge Summary
This 83-year-old has been a resident for the past 112 years. She was admitted because she had polio with left hemiparesis with speech impediment. She was
hospitalized four months ago with an exacerabation of COPD, dehydration, and low blood pressure. After physical, speech, and occupational therapy, the
patient has now become more independent and is able to walk behind her wheelchair. She is able to perform all of her ADLs. Routine lab work was
completed last week and was found to be within normal ranges. The patient is being discharged to her daughter's home.
Final Examination of Patient
The patient is alert. Vital signs: BP 120/66, P-64, R-12 weight -165 lb. HEENT: Head - normocephalic EENT: clear. NECK: No lymphadenopathy or
thyromegaly. LUNGS: Clear, good air entry.
HEART: Regular rhythm, no murmurs. Distal pulses palpable. ABDOMEN: Soft, nondistended.
NEUROLOGICAL: Cranial nerves 2-12 grossly intact except for speech impediment. Has left hemiparesis.
Discharge records were completed, and instructions and prescriptions were given to the patient's daughter.
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