Other joint derangement not elsewhere classified lower leg Tabes dorsalis Body Mass Index 45.0-49.9 adult Osteoarthrosis localized not specified whether primary or secondary lower leg Depressive disorder not elsewhere classified Asthma unspecified type unspecified Arthropathy associated with neurological disorders Obesity unspecified Knee joint replacement
 
Name:  ___                  Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   F
 
Service: ORTHOPAEDICS
 
Allergies: 
Amoxicillin / Nitrofurantoin / Augmentin / Cipro / Penicillins / 
Codeine
 
Attending: ___.
 
Chief Complaint:
right knee pain
 
Major Surgical or Invasive Procedure:
complex right total knee replacement - rotating hinge

 
History of Present Illness:
Ms ___ has had progressive right knee pain that has been 
refractory to conservative management.  She has radiographic 
evidence of severe osteoarthritis and a physical exam consistent 
with multi-directional instability.  She elects for definitive 
treatment.
 
Past Medical History:
asthma and depression

 
Social History:
___
Family History:
n/c
 
Physical Exam:
well appearing, well nourished ___ year old female
alert and oriented
no acute distress
RLE:
 -dressing-c/d/i
 -incision-c/d/i
 -+AT, FHL, ___
 -SILT
 -brisk cap refill
 -calf-soft, nontender
 -NVI distally
 
Pertinent Results:
___ 08:10AM BLOOD WBC-8.9 RBC-3.56*# Hgb-9.5*# Hct-29.0*# 
MCV-81* MCH-26.7* MCHC-32.8 RDW-15.5 Plt ___
___ 08:10AM BLOOD Glucose-116* UreaN-14 Creat-0.5 Na-134 
K-4.0 Cl-102 HCO3-26 AnGap-10
 
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.
 

Ms ___ is discharged to rehab in stable condition.

 
Medications on Admission:
sertraline, flaxseed, naproxen, and cranberry

 
Discharge Medications:
1. Sertraline 75 mg PO DAILY 
2. Lorazepam 1 mg PO BID 
3. Acetaminophen 650 mg PO Q6H 
standing dose 
4. Docusate Sodium 100 mg PO BID 
5. Enoxaparin Sodium 40 mg SC DAILY 
6. Senna 1 TAB PO BID 
7. OxycoDONE (Immediate Release)  ___ mg PO Q3H:PRN Pain 

 
Discharge Disposition:
Extended Care
 
Facility:
___
 
Discharge Diagnosis:
right charcot knee
right knee osteoarthritis
right knee multi-directional instability
 
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:
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 at first follow up appointment two 
weeks after your surgery.
7. Please call your surgeon's office to schedule or confirm your 
follow-up appointment in two (2) 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 AT FIRST POST OP 
APPOINTMENT in two (2) weeks.
11. ___ (once at home): Home ___, dressing changes as 
instructed, wound checks.
12. ACTIVITY: Weight bearing as tolerated on the operative 
extremity. Mobilize. ___ brace locked ___ degrees at all 
time x 4 weeks. No strenuous exercise or heavy lifting until 
follow up appointment.

Physical Therapy:
ROM - ___ ___ x 4 weeks
WBAT
Mobilize frequently
Treatments Frequency:
dry, sterile dressing changes daily and as needed for drainage
wound checks
ice and elevate
TEDs
 
Followup Instructions:
___

{'right knee pain': ['Osteoarthrosis', 'Knee joint replacement'], 'asthma': ['Asthma', 'unspecified type'], 'depression': ['Depressive disorder', 'not elsewhere classified'], 'multi-directional instability': ['Osteoarthrosis', 'Knee joint replacement'], 'severe osteoarthritis': ['Osteoarthrosis', 'Knee joint replacement']}