Stiffness of joint not elsewhere classified lower leg Aortic valve disorders Backache unspecified Knee joint replacement Unspecified pruritic disorder Osteoporosis unspecified Chronic pain syndrome Gouty arthropathy unspecified Pain in joint lower leg
 
Name:  ___                 Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   F
 
Service: ORTHOPAEDICS
 
Allergies: 
Niacin / Bextra / Tessalon / Fosamax / Hydromorphone
 
Attending: ___
 
___ Complaint:
Right knee stiffness s/p prior R TKA.
 
Major Surgical or Invasive Procedure:
___ R TKR manipulation under anesthesia

 
History of Present Illness:
___ had a total knee replacement in ___ after 
which she developed arthrofibrosis. She presents for definitive 
treatment.

 
Past Medical History:
mild asthma (only w/ infections), chronic pain,  
hyperlipidemia, osteoporosis, aortic stenosis.  

 
Social History:
___
Family History:
NC
 
Physical Exam:
Well appearing in no acute distress
Afebrile with stable vital signs
Pain well-controlled

Respiratory: CTAB
Cardiovascular: RRR
Gastrointestinal: NT/ND
Genitourinary: Voiding independently

Neurologic: Intact with no focal deficits
Psychiatric: Pleasant, A&O x3

Musculoskeletal Lower Extremity:

 *   Incision healed
 *   Thigh full but soft
 *   No calf tenderness
 *   ___ strength ___
 *   SILT DP/SP/T/S/S
 *   Toes warm
 
Pertinent Results:
___ 08:19AM   CALCIUM-8.9 PHOSPHATE-4.9* MAGNESIUM-2.0
___ 08:19AM   estGFR-Using this
___ 08:19AM   GLUCOSE-98 UREA N-25* CREAT-0.6 SODIUM-141 
POTASSIUM-4.1 CHLORIDE-104 TOTAL CO2-25 ANION GAP-16
 
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 
procedure was uncomplicated and the patient tolerated the 
procedure well. 

Postoperative course was remarkable for the following:

Otherwise, pain was initially controlled with a PCA + epidural 
by the pain service followed by a transition to oral pain 
medications on ___.  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 patient was seen daily by physical therapy. 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 pain was adequately controlled on an oral 
regimen. The operative extremity was neurovascularly intact and 
the wound was benign.  

At time of discharge, patient was deemed stable for safe 
discharge to home. 

The patient's weight-bearing status is weight bearing as 
tolerated
 
Medications on Admission:
Atorvastatin 40'
 
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO twice a day for 
21 days.
Disp:*42 Tablet(s)* Refills:*0*
2. Oxycodone-Acetaminophen ___ mg Tablet Sig: ___ Tablets PO 
Q3H (every 3 hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 
times a day).  
4. Atorvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY 
(Daily).  

 
Discharge Disposition:
Home with Service
 
Discharge Diagnosis:
Right knee fibroarthrosis s/p prior R TKA

 
Discharge Condition:
Mental Status: Clear and coherent.
Activity Status: Ambulatory - Independent.

 
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.
5. You may not drive a car until cleared to do so by your 
surgeon or your primary physician.
6. Call if there is an issue with your knee. 
7. Please call your surgeon's office to schedule or confirm your 
follow-up appointment in four weeks.
8. Please DO NOT take any non-steroidal anti-inflammatory 
medications (NSAIDs such as celebrex, ibuprofen, advil, aleve, 
motrin, etc).
9. ANTICOAGULATION: Please take Aspirin 325mg  TWICE  daily for 
three weeks.
10. WOUND CARE: None needed.
11. ___ (once at home): none needed. 
12. ACTIVITY: Weight bearing as tolerated on the operative 
extremity.  CPM at home.  No strenuous exercise or heavy lifting 
until follow up appointment.

Physical Therapy:
WBAT R knee. ROM as tolerated R knee. CPM to Right knee daily as 
per use in hospital.
Treatments Frequency:
None.
 
Followup Instructions:
___

{'Right knee stiffness': ['Stiffness of joint', 'Knee joint replacement'], 'Afebrile with stable vital signs': [], 'Pain well-controlled': ['Chronic pain syndrome'], 'Mild asthma': ['Aortic valve disorders'], 'Chronic pain': ['Chronic pain syndrome'], 'Hyperlipidemia': [], 'Osteoporosis': ['Osteoporosis'], 'Aortic stenosis': ['Aortic valve disorders'], 'Arthrofibrosis': ['Stiffness of joint', 'Knee joint replacement'], 'Incision healed': [], 'Thigh full but soft': [], 'No calf tenderness': [], '___ strength ___': [], 'SILT DP/SP/T/S/S': [], 'Toes warm': []}