Osteoarthrosis localized not specified whether primary or secondary pelvic region and thigh Ankylosis of joint lower leg Asthma unspecified type unspecified Unspecified hearing loss Personal history of malaria
 
Name:  ___              Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   F
 
Service: ORTHOPAEDICS
 
Allergies: 
Cats/Dogs / azithromycin
 
Attending: ___.
 
Chief Complaint:
Hip pain
 
Major Surgical or Invasive Procedure:
___ THA

 
History of Present Illness:
___ F with long standing hip pain
 
Past Medical History:
Malaria ___, low back pain, osteoarthritis both hips with 
ankylosis, hard of hearing, reactive airway disease exacerbated 
by cats and dogs, colon adenoma. Tonsillectomy, bilateral 
mastoidectomy in the 1960s.

 
Social History:
___
Family History:
NC
 
Physical Exam:
WD F in NAD
AAOx3

___
SILT L3-S1
___
+DP

Inc C/D/I
 
Brief Hospital Course:
The patient was admitted to the orthopaedic surgery service and 
was taken to the operating room for above described procedure. 
Please see separately dictated operative report for details. The 
surgery was uncomplicated and the patient tolerated the 
procedure well. Patient received perioperative IV antibiotics.

Otherwise, pain was initially controlled with a PCA followed by 
a transition to oral pain medications on POD#1.  The patient 
received lovenox for DVT prophylaxis starting on the morning of 
POD#1.  The foley was removed on POD#2 and the patient was 
voiding independently thereafter. The surgical dressing was 
changed on POD#2 and the surgical incision was found to be clean 
and intact without erythema or abnormal drainage. 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 acceptable and pain was adequately 
controlled on an oral regimen. The operative extremity was 
neurovascularly intact and the wound was benign. 

The patient's weight-bearing status is weight bearing as 
tolerated on the operative extremity with posterior precautions. 

 
Ms ___ is discharged to home with services/rehab in 
stable condition.
 
Medications on Admission:
Naproxen 500 mg twice a day, tramadol 50 mg twice a
day, vitamin D with calcium 600 mg twice a day, biotin 1000 mg
daily for hair loss.

 
Discharge Medications:
1. Enoxaparin Sodium 40 mg SC DAILY 
DVT Prophylaxsis x 4 weeks 
RX *enoxaparin 40 mg/0.4 mL 1 injection daily Disp #*28 Syringe 
Refills:*0
2. Acetaminophen 650 mg PO Q6H 
standing dose 
3. Docusate Sodium 100 mg PO BID 
4. HYDROmorphone (Dilaudid) ___ mg PO Q6H:PRN for moderate pain 
PACU ONLY 
RX *Dilaudid 2 mg ___ tablet(s) by mouth every ___ hours Disp 
#*80 Tablet Refills:*0

 
Discharge Disposition:
Home With Service
 
Facility:
___
 
Discharge Diagnosis:
Hip osteoarthritis

 
Discharge Condition:
Stable

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

2. Please follow up with your primary physician 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 drive, operate heavy machinery, or drink alcohol while 
taking these medications. As your pain decreases, take fewer 
tablets and increase the time between doses. This medication can 
cause constipation, so you should drink plenty of water daily 
and take a stool softener (such as colace) as needed to prevent 
this side effect.  Call your surgeons office 3 days before you 
are out of medication so that it can be refilled.  These 
medications cannot be called into your pharmacy and must be 
picked up in the clinic or mailed to your house.  Please allow 
an extra 2 days if you would like your medication mailed to your 
home.

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

6. Please keep your wounds clean. You may shower starting five 
(5) days after surgery, but no tub baths or swimming for at 
least four (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 the visiting nurse (___) or rehab 
facility two 
weeks after your surgery.

7. Please call your surgeon's office to schedule or confirm your 
follow-up appointment in four (4) weeks.

8. Please DO NOT take any non-steroidal anti-inflammatory 
medications (NSAIDs such as celebrex, ibuprofen, advil, aleve, 
motrin, etc).

9. ANTICOAGULATION: Please continue your lovenox for four (4) 
weeks to help prevent deep vein thrombosis (blood clots).  If 
you were taking aspirin prior to your surgery, it is OK to 
continue at your previous dose while taking this medication.  
___ STOCKINGS x 6 WEEKS.
10. WOUND CARE: Please keep your incision clean and dry. It is 
okay to shower five days after surgery but no tub baths, 
swimming, or submerging your incision until after your four (4) 
week checkup. 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 the visiting 
nurse or rehab facility in two (2) weeks.
11. ___ (once at home): Home ___, dressing changes as 
instructed, wound checks, and staple removal at two weeks after 
surgery.
12. ACTIVITY: Weight bearing as tolerated on the operative 
extremity. Posterior precautions. No strenuous exercise or heavy 
lifting until follow up appointment.  Mobilize frequently

Physical Therapy:
WBAT with posterior hip precautions
Treatments Frequency:
Daily wound check with dry dressing applied. Leave open to air 
if clean and dry. Cover and protect for soiling or shower.
 
Followup Instructions:
___

{'Hip pain': ['Osteoarthrosis'], 'Long standing hip pain': ['Osteoarthrosis'], 'Low back pain': ['Osteoarthrosis'], 'Osteoarthritis both hips with ankylosis': ['Osteoarthrosis', 'Ankylosis of joint'], 'Hard of hearing': ['Unspecified hearing loss'], 'Reactive airway disease exacerbated by cats and dogs': ['Asthma'], 'Colon adenoma': []}