Osteoarthritis of knee unspecified Chronic obstructive pulmonary disease unspecified Unspecified asthma uncomplicated Obstructive sleep apnea (adult) (pediatric) Other chronic pain Pain in unspecified joint Sciatica right side Obesity unspecified Body mass index [BMI] 40.0-44.9 adult Gastro-esophageal reflux disease without esophagitis Nicotine dependence cigarettes uncomplicated Personal history of other venous thrombosis and embolism Long term (current) use of antithrombotics/antiplatelets
 
Name:  ___                Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   F
 
Service: ORTHOPAEDICS
 
Allergies: 
aspirin / Penicillins / latex
 
Attending: ___.
 
Chief Complaint:
right knee pain
 
Major Surgical or Invasive Procedure:
none

 
History of Present Illness:
___ with right knee pain presenting for elective total knee 
arthroplasty
 
Past Medical History:
MVA in ___ with likely R ankle ATFL tear-> no ___ but dev 
RLE DVT now on xarelto
-Right knee medial meniscectomy ___ ___, ___
-Asthma
-Bilateral carpal tunnel syndrome
-Osteoarthritis
-Polyarthralgia
-Chronic pain
-Complex regional pain syndrome
-GERD
-Right-sided sciatica
-Right shoulder arthroscopy
-Endometrial ablation
-Tubal ligation
-Cholecystectomy
-Appendectomy

 
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 healing well with staples  
* Scant serosanguinous drainage  
* Thigh full but soft  
* No calf tenderness  
* ___ strength  
* SILT, NVI distally  
* Toes warm

 
Brief Hospital Course:
The patient was admitted to the orthopedic surgery service and 
was taken to the operating room for above described procedure. 
On day of surgery, patient was unable to be intubated secondary 
to airway difficulties; thus surgery was aborted. She will 
reschedule her surgery in the next few months.

During her hospitalization, surgery was aborted secondary to 
airway difficulty and inability to intubate.

Otherwise, pain was controlled with oral pain medications. 

The patient's weight-bearing status is weight bearing as 
tolerated on the affected extremity.
 
Ms ___ is discharged to home in stable condition.

 
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. butalbital-acetaminophen 50-325 mg oral DAILY:PRN 
2. Gabapentin 800 mg PO TID 
3. Dronabinol Dose is Unknown  PO Frequency is Unknown 
4. aclidinium bromide 400 mcg/actuation inhalation BID 
5. Zolpidem Tartrate 10 mg PO QHS 
6. Rivaroxaban 20 mg PO DAILY 
7. TraMADol 50 mg PO TID 
8. Budesonide Nasal Inhaler 180 mcg/actuation nasal DAILY 
9. Omeprazole 20 mg PO DAILY 
10. Loratadine 10 mg PO DAILY 
11. albuterol sulfate 90 mcg/actuation inhalation DAILY:PRN 
shortness of breath or wheezing 

 
Discharge Medications:
1.  Acetaminophen 1000 mg PO Q8H 
RX *acetaminophen 500 mg 2 tablet(s) by mouth every eight (8) 
hours Disp #*100 Tablet Refills:*0 
2.  Docusate Sodium 100 mg PO BID 
RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp 
#*100 Tablet Refills:*0 
3.  Senna 8.6 mg PO BID 
RX *sennosides [senna] 8.6 mg 1 tab by mouth twice a day Disp 
#*100 Tablet Refills:*0 
4.  Dronabinol unknown  PO Frequency is Unknown  
5.  aclidinium bromide 400 mcg/actuation inhalation BID  
6.  albuterol sulfate 90 mcg/actuation inhalation DAILY:PRN  
7.  Budesonide Nasal Inhaler 180 mcg/actuation nasal DAILY  
8.  butalbital-acetaminophen 50-325 mg oral DAILY:PRN  
9.  Gabapentin 800 mg PO TID  
10.  Loratadine 10 mg PO DAILY  
11.  Omeprazole 20 mg PO DAILY  
12.  Rivaroxaban 20 mg PO DAILY  
13.  TraMADol 50 mg PO TID  
14.  Zolpidem Tartrate 10 mg PO QHS  

 
Discharge Disposition:
Home
 
Discharge Diagnosis:
right knee pain/osteoarthritis

 
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.

 
Discharge Instructions:
Please reschedule your surgery to ___. You will need 
re-evaluation and preoperative assessment.

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.
 
Please follow up with your primary physician regarding this 
admission and any new medications and refills. 
 
Resume your home medications unless otherwise instructed.
 
 ACTIVITY: Weight bearing as tolerated on the operative 
extremity. Mobilize.  ROM as tolerated. 

Physical Therapy:
none
Treatments Frequency:
none
 
Followup Instructions:
___

{'right knee pain': ['Osteoarthritis of knee'], 'airway difficulties': [], 'inability to intubate': [], 'shortness of breath': ['Chronic obstructive pulmonary disease', 'Obstructive sleep apnea (adult) (pediatric)'], 'wheezing': ['Unspecified asthma'], 'chronic pain': ['Other chronic pain'], 'polyarthralgia': [], 'complex regional pain syndrome': [], 'GERD': ['Gastro-esophageal reflux disease without esophagitis'], 'right-sided sciatica': ['Sciatica', 'right side'], 'obesity': ['Obesity', 'unspecified', 'Body mass index [BMI] 40.0-44.9', 'adult'], 'nicotine dependence': ['Nicotine dependence', 'cigarettes', 'uncomplicated'], 'DVT': ['Personal history of other venous thrombosis and embolism'], 'long term (current) use of antithrombotics/antiplatelets': ['Long term (current) use of antithrombotics/antiplatelets']}