Osteoarthrosis localized not specified whether primary or secondary lower leg Asthma unspecified type unspecified Aortic valve disorders Osteoporosis unspecified Gout unspecified
 
Name:  ___                 Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   F
 
Service: ORTHOPAEDICS
 
Allergies: 
Niacin / Bextra / Tessalon / Fosamax / Hydromorphone
 
Attending: ___
 
___ Complaint:
Progressive right knee pain with activity
 
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 progressive right knee pain with activity.  
She presents for definitive treatment.
 
Past Medical History:
mild asthma (only w/ infections), chronic pain,  
hyperlipidemia, osteoporosis, aortic stenosis.  

 
Social History:
___
Family History:
___
 
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
Extensor/flexor hallicus longus intact  
Sensation intact to light touch  
Neurovascular intact distally  
Capillary refill brisk  
2+ pulses 

 
Pertinent Results:
___ 10:37AM BLOOD WBC-8.1 RBC-3.71* Hgb-10.5* Hct-31.7* 
MCV-85 MCH-28.3 MCHC-33.2 RDW-13.8 Plt ___
___ 07:25AM BLOOD Hct-28.6*
___ 06:50AM BLOOD Hct-25.6*
___ 06:30AM BLOOD Hct-26.9*
 
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 POD#2 she received one 
unit PRBC's for post operative anemia.  She had a fever to 101.3 
at the end of the transfusion and the transfusion reaction 
protocol was followed.  On the floor, she remained 
hemodynamically stable with her pain was controlled. She 
progressed with physical therapy to improve her strength and 
mobility. She was discharged in stable condition. 
 
Medications on Admission:
Lipitor 80 daily, Flonase 50mcg BID, Vit D, Calcium 
 
Discharge Medications:
1. Enoxaparin 40 mg/0.4 mL Syringe Sig: One (1)  Subcutaneous 
Q24H (every 24 hours).  
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 
times a day).  
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One 
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).  
4. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) 
Tablet PO DAILY (Daily).  
5. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) 
Tablet, Chewable PO TID (3 times a day).  
6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a 
day) as needed for Constipation.  
7. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY 
(Daily).  
8. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1) 
Spray Nasal BID (2 times a day) as needed for allergies.  
9. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 
6 hours).  
10. Oxycodone 5 mg Tablet Sig: ___ Tablets PO Q3H (every 3 
hours) as needed for Pain.  
11. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) 
ML PO Q6H (every 6 hours) as needed for constipation.  
12. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal 
BID (2 times a day) as needed for constipation.  

 
Discharge Disposition:
Extended Care
 
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/walker for ambulation. 

Please 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 
take only as directed and do not drive or operate any machinery 
while taking this medication.  There is a 72 hour ___ 
through ___, 9am to 4pm) response time for prescription refil 
requests.  There will be no prescription refils on ___, 
___, or holidays.  Please plan accordingly.    

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

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. 

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'], 'activity': ['Osteoarthrosis'], 'asthma': ['Asthma'], 'hyperlipidemia': [], 'aortic stenosis': ['Aortic valve disorders'], 'osteoporosis': ['Osteoporosis']}