Osteoarthrosis localized not specified whether primary or secondary pelvic region and thigh Unspecified essential hypertension Lumbago Tobacco use disorder Esophageal reflux Hip joint replacement
 
Name:  ___                     Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   F
 
Service: ORTHOPAEDICS
 
Allergies: 
Penicillins
 
Attending: ___.
 
Chief Complaint:
L hip OA
 
Major Surgical or Invasive Procedure:
L THR

 
History of Present Illness:
___ with L hip OA
 
Past Medical History:
R shoulder rotator cuff tear s/p surgical repair, hypertension, 
chronic LBP
 
Social History:
___
Family History:
Family history is noncontributory.

 
Physical Exam:
At the time of discharge:
AVSS
NAD
wound c/d/i without erythema
___ intact
SILT distally
 
Pertinent Results:
___ 06:20AM BLOOD WBC-7.9 RBC-2.49* Hgb-8.2* Hct-23.8* 
MCV-96 MCH-32.9* MCHC-34.4 RDW-12.5 Plt ___
___ 06:10AM BLOOD WBC-7.0 RBC-2.90*# Hgb-9.7* Hct-27.8* 
MCV-96 MCH-33.3* MCHC-34.8 RDW-12.4 Plt ___
___ 06:20AM BLOOD Plt ___
___ 06:10AM BLOOD Plt ___
___ 06:10AM BLOOD Glucose-106* UreaN-7 Creat-0.9 Na-139 
K-3.4 Cl-106 HCO3-29 AnGap-7*
___ 06:10AM BLOOD Calcium-8.1* Phos-3.7 Mg-1.7
 
Brief Hospital Course:
The patient was admitted on ___ and, later that day, was 
taken to the operating room by Dr. ___ L THR without 
complication.  Please see operative report for details. 
Postoperatively the patient did well.  The patient was initially 
treated with a PCA followed by PO pain medications on POD#1.  
The patient received IV antibiotics for 24 hours 
postoperatively, as well as lovenox for DVT prophylaxis starting 
on the morning of POD#1.  The drain was removed without incident 
on POD#1. The Foley catheter was removed without incident. The 
surgical dressing was removed on POD#2 and the surgical incision 
was found to be clean, dry, and intact without erythema or 
purulent drainage.
 
While in the hospital, the patient was seen daily by physical 
therapy. Labs were checked throughout the hospital course and 
repleted accordingly. At the time of discharge the patient was 
tolerating a regular diet and feeling well.  The patient was 
afebrile with stable vital signs. The patient's hematocrit was 
stable, and the patient's pain was adequately controlled on a PO 
regimen. The operative extremity was neurovascularly intact and 
the wound was benign. The patient was discharged to home with 
services in a stable condition.  The patient's weight-bearing 
status was WBAT.
 
Medications on Admission:
cymbalta, neurontin, topamax, verapamil, vit D
 
Discharge Medications:
1. Vitamin D 400 unit Tablet Sig: One (1) Tablet PO once a day.  

2. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) 
Tablet, Chewable PO TID (3 times a day).  
3. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) 
Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Multivitamin     Tablet Sig: One (1) Cap PO DAILY (Daily).  
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 
times a day).
Disp:*60 Capsule(s)* Refills:*2*
6. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 
4 hours).  
7. Oxycodone 5 mg Tablet Sig: ___ Tablets PO Q4H (every 4 hours) 
as needed for pain: Do not drink, drive or operate heavy 
machinery while taking this medication.
Disp:*80 Tablet(s)* Refills:*0*
8. Duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: One (1) 
Capsule, Delayed Release(E.C.) PO DAILY (Daily).  
9. Gabapentin 400 mg Capsule Sig: Three (3) Capsule PO Q12H 
(every 12 hours).  
10. Topiramate 25 mg Tablet Sig: Two (2) Tablet PO BID (2 times 
a day).  
11. Verapamil 240 mg Tablet Sustained Release Sig: One (1) 
Tablet Sustained Release PO Q24H (every 24 hours).  
12. Enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) syringe 
Subcutaneous DAILY (Daily) for 3 weeks: To be followed by 
aspirin 325mg twice daily for 3 weeks.
Disp:*21 syringe* Refills:*0*

 
Discharge Disposition:
Home With Service
 
Facility:
___
 
Discharge Diagnosis:
L hip OA

 
Discharge Condition:
Stable

 
Discharge Instructions:
1. Please return to the emergency department or notify MD if you 
experience severe pain not relieved by medication, increased 
swelling, decreased sensation, difficulty with movement, fevers 
>101.5, shaking chills, redness or drainage from the incision 
site, chest pain, shortness of breath or any other concerns.

2. Please follow up with your PCP regarding this admission and 
any new medications and refills.
 
3. Resume your home medications unless otherwise instructed.
 
4. You have been given medications for pain control. Please do 
not operate heavy machinery or drink alcohol when taking these 
medications. As your pain improves, please decrease the amount 
of pain medication. This medication can cause constipation, so 
you should drink plenty of water daily and take a stool softener 
(e.g., colace) as needed to prevent this side effect.

5. You may not drive a car until cleared to do so by your 
surgeon or your primary physician.

6. Please keep your wounds clean. You may get the wound wet or 
take a shower starting 5 days after surgery, but no baths or 
swimming for at least 4 weeks. No dressing is needed if wound 
continues to be non-draining. Any stitches or staples that need 
to be removed will be taken out by a visiting nurse at 2 weeks 
after your surgery.

7. Please call your surgeon's office to schedule or confirm your 
follow-up appointment at 4 weeks.

8. Please DO NOT take any NSAIDs (i.e. celebrex, ibuprofen, 
advil, motrin, etc).
 
9. ANTICOAGULATION: Please continue your lovenox for 3 weeks to 
prevent deep vein thrombosis (blood clots).  After completing 
the lovenox, please take Aspirin 325mg twice daily for an 
additional three weeks.
 
10. WOUND CARE: Please keep your incision clean and dry. It is 
okay to shower after POD#5 but do not take a tub-bath or 
submerge your incision until 4 weeks after surgery. Please place 
a dry sterile dressing on the wound each day if there is 
drainage, otherwise leave it open to air. Check wound regularly 
for signs of infection such as redness or thick yellow drainage. 
Staples will be removed by ___ in 2 weeks. If you are going to 
rehab, the rehab facility can remove the staples at 2 weeks.
 
11. ___ (once at home): Home ___, dressing changes as 
instructed, wound checks, and staple removal at 2 weeks after 
surgery.
 
12. ACTIVITY: Weight bearing as tolerated on the operative leg. 
No strenuous exercise or heavy lifting until follow up 
appointment.
Physical Therapy:
WBAT
Treatments Frequency:
Physical therapy.  Lovenox injections. Wound checks. ___ to 
remove staples at 2 weeks.
 
Followup Instructions:
___

{'L hip OA': ['Osteoarthrosis', 'pelvic region and thigh'], 'hypertension': ['Unspecified essential hypertension'], 'chronic LBP': ['Lumbago'], 'smoking history': ['Tobacco use disorder'], 'GERD': ['Esophageal reflux'], 'L THR': ['Hip joint replacement']}