Osteoarthrosis localized not specified whether primary or secondary lower leg Obesity unspecified
 
Name:  ___                  Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   F
 
Service: ORTHOPAEDICS
 
Allergies: 
Amoxicillin / Codeine
 
Attending: ___.
 
Chief Complaint:
left knee osteoarthritis
 
Major Surgical or Invasive Procedure:
___ - Complex primary left total knee arthroplasty with 
stems and total stabilizer tibial insert

 
History of Present Illness:
___ with left knee pain from osteoarthritis who failed 
conservative management. 
 
Past Medical History:
OA, obesity, umbilical hernia
 
Social History:
___
Family History:
n/c
 
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 healing well with staples
 *   Scant serosanguinous drainage
 *   Thigh full but soft
 *   No calf tenderness
 *   ___ strength ___
 *   SILT DP/SP/T/S/S
 *   Toes warm

 
Pertinent Results:
___ 07:10AM BLOOD WBC-9.8 RBC-3.35* Hgb-9.5* Hct-29.1* 
MCV-87 MCH-28.3 MCHC-32.6 RDW-13.9 Plt ___
___ 06:15AM BLOOD Glucose-114* UreaN-9 Creat-0.4 Na-133 
K-4.3 Cl-99 HCO3-24 AnGap-14
___ 06:15AM BLOOD Calcium-8.7 Phos-4.5 Mg-2.0
 
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.

Postoperative course was remarkable.  She followed standard knee 
pathway but she required an unlocked ___ brace at all times 
given her complex knee surgery.

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 with posterior hip 
precautions. 

 
Medications on Admission:
celexa 60, ativan, naprosyn
 
Discharge Medications:
1. Lovenox 40 mg/0.4 mL Syringe Sig: One (1) syringe 
Subcutaneous once a day for 3 weeks: Please continue lovenox for 
3 wks. Once lovenox is finished take aspirin 325mg twice daily 
for 3 wks.
Disp:*21 syringes* Refills:*0*
2. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) 
Tablet, Delayed Release (E.C.) PO twice a day for 3 weeks: take 
for 3 wks once you're done with the lovenox.
Disp:*42 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
3. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 
6 hours).  
4. Oxycodone 5 mg Tablet Sig: ___ Tablets PO Q3H (every 3 hours) 
as needed for Pain.
Disp:*90 Tablet(s)* Refills:*0*
5. Citalopram 20 mg Tablet Sig: Three (3) Tablet PO DAILY 
(Daily).  
6. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 
hours) as needed for Anxiety.  
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 
times a day).  
8. Ferrous Sulfate 300  mg (60 mg Iron) Tablet Sig: One (1) 
Tablet PO DAILY (Daily).  
9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a 
day) as needed for Constipation.  
10. Multivitamin     Tablet Sig: One (1) Cap PO DAILY (Daily).  
11. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) 
Tablet, Chewable PO TID (3 times a day).  

 
Discharge Disposition:
Extended Care
 
Facility:
___
 
Discharge Diagnosis:
left knee osteoarthritis

 
Discharge Condition:
Mental Status: Clear and coherent
Level of Consciousness: Alert and interactive
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. Please keep your wounds clean. You may shower starting five 
days after surgery, but no tub baths or swimming for at least 
four 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 by the visiting nurse or rehab facility two 
weeks after your surgery.
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 continue your lovenox for three weeks 
to help prevent deep vein thrombosis (blood clots).  After 
completing the lovenox, please take Aspirin 325mg  TWICE  daily 
for an additional three 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 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 by the visiting nurse or rehab facility 
in two weeks.
11. ___ (once at home): Home ___, dressing changes as 
instructed, wound checks, and staple removal at two weeks after 
surgery.
12. ACTIVITY: Weight bearing as tolerated on the operative 
extremity. Wear your ___ brace unlocked for 2months. No 
strenuous exercise or heavy lifting until follow up appointment.

Physical Therapy:
Weight bearing as tolerated on the operative extremity. CPM as 
tolerated.  No strenuous exercise or heavy lifting until follow 
up appointment.
Treatments Frequency:
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 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 by the visiting nurse or rehab facility 
in two weeks.
 
Followup Instructions:
___

{'left knee pain': ['Osteoarthrosis'], 'umbilical hernia': ['Obesity']}