Osteoarthrosis localized not specified whether primary or secondary lower leg Other and unspecified angina pectoris Unspecified essential hypertension Mitral valve disorders Psoriatic arthropathy
 
Name:  ___                   Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   F
 
Service: ORTHOPAEDICS
 
Allergies: 
Lipitor / Lidocaine / Penicillins / Sulfa (Sulfonamides) / IV 
Dye, Iodine Containing
 
Attending: ___
 
___ Complaint:
Progressive right knee pain
 
Major Surgical or Invasive Procedure:
Right total knee replacement

 
History of Present Illness:
Ms. ___ is a ___ year old female with a history of 
osteoarthritis and right knee pain presents for definitive 
treatment.
 
Past Medical History:
Angina
Hypertension
Mitral valve prolapse
Dyspnea
Hiatal hernia
GERD
Thyroid disease
Psoriatic arthritis
s/p tonsillectomy
s/p appendectomy
s/p knee arthroscopy
 
Social History:
___
Family History:
NC
 
Physical Exam:
On discharge: 
Afebrile, All vital signs stable
General: Alert and oriented, No acute distress
Extremities: right lower
Weight bearing: partial weight bearing
Incision: intact, no swelling/erythema/drainage
Dressing: clean/dry/intact
  Sensation intact to light touch
  Neurovascular intact distally
  Capillary refill brisk
  2+ pulses 

 
Pertinent Results:
___ 05:30AM BLOOD WBC-14.0* RBC-3.38* Hgb-10.5* Hct-30.7* 
MCV-91 MCH-31.2 MCHC-34.4 RDW-13.2 Plt ___
___ 05:30AM BLOOD Glucose-120* UreaN-12 Creat-0.9 Na-135 
K-4.6 Cl-102 HCO3-26 AnGap-12
 
Brief Hospital Course:
Ms. ___ was admitted to ___ on ___ for an elective right 
total knee replacement. Pre-operatively, she was consented, 
prepped, and brought to the operating room. Intra-operatively, 
she was closely monitored and remained hemodynamically stable. 
She tolerated the procedure well without any complication. 
Post-operatively, she was transferred to the PACU and floor for 
further recovery. On the floor,post operative day one drain was 
removed.  She remained hemodynamically stable.  Her pain was 
controlled. She progressed with physical therapy to improve her 
strength and mobility. She was discharged today in stable 
condition. 

 
Medications on Admission:
Atenolol
Norvasc
Diovan
Zetia
Trazadone
Protonix
Vicoden
Allegra
Colace
Calcium
MVI
Pantanol
 
Discharge Medications:
1. Lovenox 40 mg/0.4 mL Syringe Sig: One (1) syringe 
Subcutaneous once a day for 3 weeks.
Disp:*21 * Refills:*0*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 
times a day).
Disp:*60 Capsule(s)* Refills:*2*
3. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) 
ML PO BID (2 times a day) as needed.  
4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a 
day) as needed.  
5. Multivitamin     Tablet Sig: One (1) Cap PO DAILY (Daily).  
6. Diphenhydramine HCl 25 mg Capsule Sig: ___ Capsules PO Q6H 
(every 6 hours) as needed.  
7. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) 
Tablet, Chewable PO TID (3 times a day).  
8. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) 
Tablet PO DAILY (Daily).  
9. Atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).  
10. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 
 
11. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 
 
12. traZODONE 150 mg Tablet Sig: One (1) Tablet PO HS (at 
bedtime) as needed.  
13. Fexofenadine 60 mg Tablet Sig: Three (3) Tablet PO DAILY 
(Daily).  
14. Valsartan 160 mg Tablet Sig: Two (2) Tablet PO DAILY 
(Daily).  
15. Oxycodone 5 mg Tablet Sig: ___ Tablets PO Q4-6H () as 
needed.
Disp:*80 Tablet(s)* Refills:*0*

 
Discharge Disposition:
Home With Service
 
Facility:
___
 
Discharge Diagnosis:
Osteoarthritis

 
Discharge Condition:
Stable

 
Discharge Instructions:
If you experience any shortness of breath, new 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 use your crutches 
for ambulation.
You may resume all of the medications you took prior to your 
hospital admission. Take all medication as prescribed by your 
doctor. 
You have been prescribed a narcotic pain medication. Please do 
not drive or operate any machinery while taking this medication.
Continue your Lovenox injections as prescribed to help prevent 
blood clots.  Please finish all of this medication.
Feel free to call our office with any questions or concerns. 
Physical Therapy:
Activity:  Activity as tolerated
 Right lower extremity:  Partial weight bearing
 Knee immobilizer:  when not in CPM and at bedtime

Treatments Frequency:
Keep your incision/dressing clean and dry. Apply a dry sterile 
dressing daily as needed for drainage or comfort. Keep your knee 
dry for 5 days after your surgery.  After 5 days you may shower, 
but make sure that you keep your incision dry. 
Your skin staples may be removed 2 weeks after your surgery or 
at the time of your follow up visit. 
 
Followup Instructions:
___

{'right knee pain': ['Osteoarthrosis'], 'angina': ['Other and unspecified angina pectoris'], 'hypertension': ['Unspecified essential hypertension'], 'mitral valve prolapse': ['Mitral valve disorders'], 'dyspnea': [], 'hiatal hernia': [], 'GERD': [], 'thyroid disease': [], 'psoriatic arthritis': ['Psoriatic arthropathy']}