Infection and inflammatory reaction due to internal joint prosthesis Pyogenic arthritis lower leg Knee joint replacement Surgical operation with implant of artificial internal device causing abnormal patient reaction or later complication,without mention of misadventure at time of operation Postsurgical hypothyroidism Unspecified essential hypertension Lumbago Person awaiting admission to adequate facility elsewhere Streptococcus infection in conditions classified elsewhere and of unspecified site other streptococcus
 
Name:  ___.                 Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   F
 
Service: ORTHOPAEDICS
 
Allergies: 
Aspirin / Adhesive Tape / Percocet / Erythromycin Base / Bee 
Sting Kit / Adhesive Bandages / Caffeine
 
Attending: ___
 
___ Complaint:
right knee pain
 
Major Surgical or Invasive Procedure:
I&D Right TKA

 
History of Present Illness:
___ y/o woman s/p TKA presents with infected knee and underwent 
I&D with liner exchange.
 
Past Medical History:
1. Hypertension 
2. Hypothyroidism, status post partial thyroidectomy for 
multinodular goiter 
3. Arthritis 
4. Spinal stenosis 
5. Chronic low back pain 
6. Mitral valve prolapse 
7. Irritable bowel syndrome
8. Cerebral Aneurysm

 
Social History:
___
Family History:
Positive for breast cancer in the patient's mother. Brother and 
father both status post CABG. Brother with type ___ diabetes.

 
Physical Exam:
Afebrile, All vital signs stable 
General: NCAT, NAD

Pulm: lungs CTA bilaterally, no w/r/r

Card:s1/s2 clear no m/g/r

Abd: soft NT/ND, +BS

Ext: incision C/D/I calf nt nvi distally

 
Pertinent Results:
___ 05:36PM JOINT FLUID  ___ POLYS-97* 
___ ___ 04:20PM   CRP-130.9*
___ 04:20PM   SED RATE-67*
___ 11:30AM BLOOD WBC-9.3 RBC-3.92* Hgb-11.0* Hct-33.4* 
MCV-85 MCH-28.1 MCHC-33.0 RDW-13.6 Plt ___
___ 11:30AM BLOOD ESR-67*
___ 11:30AM BLOOD Glucose-112* UreaN-28* Creat-0.8 Na-140 
K-4.2 Cl-102 HCO3-29 AnGap-13
___ 11:30AM BLOOD CRP-12.7*
 
Brief Hospital Course:
Ms. ___ was admitted to ___ on ___ for right septic 
knee s/p B TKAs in ___. Pre-operatively, she was consented and 
history and physical performed. Intra-operatively, she was 
closely monitored and remained stable. She tolerated the 
procedure well without any difficulty. Post-operatively, she was 
transferred to the PACU and floor for further recovery. On the 
floor,she remained stable. Her pain was well controlled. She 
progressed with physical therapy to improve her strength and 
mobility.  On ___ she was changed from vancomycin to 
Ceftriaxone 2g iv q 24 hours and tolerated this well. She 
continued to make steady progress. She was discharged to a 
rehabilitation facility in stable condition. 

 
Medications on Admission:
levothyroxine, valsartan, venlafaxine, gabapentin, calcium, 
vitamins
 
Discharge Medications:
1. Enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) syringe 
Subcutaneous DAILY (Daily) for 3 weeks.
Disp:*21 syringe* Refills:*0*
2. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY 
(Daily).  
3. Valsartan 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).  

4. Venlafaxine 75 mg Capsule, Sust. Release 24 hr Sig: One (1) 
Capsule, Sust. Release 24 hr PO HS (at bedtime).  
5. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO TID, PRN () 
as needed for pain.  
6. Hydromorphone 2 mg Tablet Sig: ___ Tablets PO Q3H (every 3 
hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 
times a day).  
8. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) 
ML PO BID (2 times a day) as needed for Constipation.  
9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a 
day) as needed for Constipation.  
10. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) 
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for 
Constipation.  
11. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: One (1) ML 
Intravenous PRN (as needed) as needed for line flush.  
12. Ceftriaxone in Dextrose,Iso-os 2 gram/50 mL Piggyback Sig: 
One (1)  Intravenous Q24H (every 24 hours) for 6 weeks: until 
___ when has follow up with ID.
Disp:*28 * Refills:*0*
13. PICC line care  Sig: One (1)   daily: PICC line care as per 
protocol.
Disp:*1 * Refills:*2*
14. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One 
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).  
15. B Complex Vitamins     Capsule Sig: One (1) Cap PO DAILY 
(Daily).  
16. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) 
Tablet PO DAILY (Daily).  
17. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) 
Tablet, Chewable PO TID (3 times a day).  
18. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 
 
19. Acetaminophen 500 mg Tablet Sig: ___ Tablets PO every six 
(6) hours as needed for fever.  
20. Ondansetron HCl (PF) 4 mg/2 mL Solution Sig: One (1)  
Injection Q8H (every 8 hours) as needed for nausea/vomiting.  

 
Discharge Disposition:
Extended Care
 
Facility:
___
 
Discharge Diagnosis:
septic right TKA

 
Discharge Condition:
Mental Status: Clear and coherent
Level of Consciousness: Alert and interactive
Activity Status: Ambulatory - requires assistance or aid (walker 
or cane)

 
Discharge Instructions:
Keep the incision clean and dry. Please apply a dry sterile 
dressing daily as needed for drainage or comfort. 

If you have any shortness of breath, increased redness, 
increased swelling, pain, or drainage, or have a temperature 
>101, please call your doctor or go to the emergency room for 
evaluation. 

You may bear weight on your right leg. 

Please resume all of the medications you took prior to your 
admission unless discussed with your provider. Take all 
medication as prescribed by your provider. 

Please take an aspirin daily to help reduce the chances of 
developing a blood clot. 

Feel free to call our office with any questions or concerns. 

Physical Therapy:
CPM advance as tolerated ___
no restrictions on ROM or weight bearing
Treatments Frequency:
ice and elevate as tolerated
 
Followup Instructions:
___

{'right knee pain': ['Infection and inflammatory reaction due to internal joint prosthesis', 'Pyogenic arthritis', 'Knee joint replacement'], 'Hypertension': ['Unspecified essential hypertension'], 'Hypothyroidism': ['Postsurgical hypothyroidism'], 'Arthritis': ['Infection and inflammatory reaction due to internal joint prosthesis', 'Pyogenic arthritis'], 'Spinal stenosis': [], 'Chronic low back pain': ['Lumbago'], 'Mitral valve prolapse': [], 'Irritable bowel syndrome': [], 'Cerebral Aneurysm': []}