Other postoperative infection Methicillin resistant Staphylococcus aureus in conditions classified elsewhere and of unspecified site Other specified surgical operations and procedures causing abnormal patient reaction or later complication without mention of misadventure at time of operation Postsurgical hypothyroidism Mitral valve disorders Knee joint replacement Unspecified essential hypertension Irritable bowel syndrome Lumbago
 
Name:  ___.                 Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   F
 
Service: ORTHOPAEDICS
 
Allergies: 
Aspirin / Adhesive Tape / Percocet / Erythromycin Base / Bee 
Sting Kit / adhesive bandage / Caffeine
 
Attending: ___.
 
Chief Complaint:
Wound infection
 
Major Surgical or Invasive Procedure:
Washout of lumbar incision

 
History of Present Illness:
___ with pmhx of chronic LBP ___ steroid injections), sp bl TKR, 
cerebral aneurysm sp clipping, hypothyroidism (sp L 
hemithyroidectomy), sp ccy, sp tonsillectomy, sp TAH (fibroids), 
sp R oopheretomy), sp appy, sp CTS release with recent lumbar 
laminectomy L2-5 with L3-5 fusion on ___ by Dr. ___ 
presents with fever. Patient states that for the past two days 
she has had worsening pain and redness at her operative site. 
She denies any new lower extremity weakness, parasthesias or 
anesthesia. She does endorse occasional urinary incontinence she 
attributes to difficulty reaching commode in time. Denies fecal 
incontinence, saddle anesthesia. Denies CP, dyspnea, cough, abd 
pain, dysuria. 
 
Past Medical History:
1. Hypertension 
2. Hypothyroidism, status post partial thyroidectomy for 
multinodular goiter 
3. Arthritis 
4. Spinal stenosis 
5. Chronic low back pain 
6. Mitral valve prolapse 
7. Irritable bowel syndrome
8. Cerebral Aneurysm

 
Social History:
___
Family History:
Positive for breast cancer in the patient's mother. Brother and 
father both status post CABG. Brother with type ___ diabetes.

 
Physical Exam:
In general, the patient is a  
Vitals: T 102.7dF Hr 93 BP 127/77 RR 18 SpO2 96% RA  
Spine exam:  
Wound: Midline lumbar spine wound from L1-L5 has surrounding 
blanching erthema and induration, no clear fluctuance. No 
discharge.  
Vascular  
Radial: L2+, R2+  
DPR: L2+, R2+  
Motor-  
Delt Bic Tri WrE FFl FE IO IP glut Quad Ham TA Gastroc  
L ___ 5  
R ___ 5  
-Sensory:  
Sensory UE  
C5 (Ax) R nl, L nl  
C6 (MC) R nl, L nl  
C7 (Mid finger) R nl, L nl  
C8 (MACN) R nl, L nl  
T1 (MBCN) R nl, L nl  
T2-L2 Trunk R nl, L nl  
Sensory ___  
L2 (Groin): R nl, L nl  
L3 (Leg) R nl, L nl  
L4 (Knee) R nl, L nl  
L5 (Grt Toe): R nl, L nl  
S1 (Sm toe): R nl, L nl  
S2 (Post Thigh): R nl, L nl  
-DTRs:  
Bi Tri ___ Pat Ach  
L ___ 2 2  
R ___ 2 2  
Plantar response was extensor bilaterally.  
___: neg  
Babinski: downgoing  
Clonus: none  
Perianal sensation: intact  
Rectal tone: intact  

 
Pertinent Results:
___ 06:50PM BLOOD WBC-11.5* RBC-3.75* Hgb-10.3* Hct-32.9* 
MCV-88 MCH-27.4 MCHC-31.3 RDW-14.4 Plt ___
___ 10:10AM BLOOD WBC-13.3* RBC-3.54* Hgb-9.9* Hct-31.4* 
MCV-89 MCH-28.0 MCHC-31.6 RDW-14.2 Plt ___
___ 03:27PM BLOOD WBC-14.2* RBC-4.03* Hgb-10.9* Hct-35.0* 
MCV-87 MCH-27.0 MCHC-31.1 RDW-14.2 Plt ___
___ 03:27PM BLOOD Neuts-82.2* Lymphs-11.1* Monos-5.9 
Eos-0.4 Baso-0.3
___ 06:50PM BLOOD ESR-128*
___ 03:27PM BLOOD ESR-92*
___ 06:50PM BLOOD Glucose-100 UreaN-13 Creat-0.8 Na-145 
K-4.5 Cl-99 HCO3-31 AnGap-20
___ 10:10AM BLOOD Glucose-134* UreaN-17 Creat-0.8 Na-139 
K-4.2 Cl-102 HCO3-28 AnGap-13
___ 03:27PM BLOOD Glucose-102* UreaN-17 Creat-0.8 Na-139 
K-4.3 Cl-98 HCO3-29 AnGap-16
___ 09:55AM BLOOD Vanco-15.2
___ 08:45PM BLOOD Genta-4.0* Vanco-14.0
 
Brief Hospital Course:
Ms. ___ underwent a washout of her posterior lumbar incision. 
 She had a PICC line placed and will receive 10 weeks of IV 
vancomycin.  She will follow up with both the ___ clinic and Dr. 
___.
 
Medications on Admission:
Trazodone
Venlafaxine
Pramipexole
Synthroid
 
Discharge Medications:
1. Heparin Flush (10 units/ml) 2 mL IV DAILY and PRN, line flush 

2. HYDROmorphone (Dilaudid) 2 mg PO Q4H:PRN pain 
RX *hydromorphone [Dilaudid] 2 mg 1 tablet(s) by mouth every 
four (4) hours Disp #*100 Tablet Refills:*0
3. Levothyroxine Sodium 50 mcg PO DAILY 
4. pramipexole 0.25 mg oral TID restless leg 
5. TraZODone 100 mg PO HS:PRN insomnia 
6. Venlafaxine 200 mg PO QHS 
7. Vancomycin 1000 mg IV Q 12H X 10 weeks 

 
Discharge Disposition:
Extended Care
 
Facility:
___
 
Discharge Diagnosis:
Lumbar incision infection

 
Discharge Condition:
Good

 
Discharge Instructions:
You have undergone the following operation: Washout lumbar 
incision 

 
Immediately after the operation:
 

 
-Activity: You should not lift anything greater than 10 lbs for 
2 weeks. You will be more comfortable if you do not sit or stand 
more than ~45 minutes without getting up and walking around.
 

 
-Rehabilitation/ Physical Therapy: 
 
o2-3 times a day you should go for a walk for ___ minutes as 
part of your recovery. You can walk as much as you can tolerate. 

 
oLimit any kind of lifting.
 

 
-Diet: Eat a normal healthy diet. You may have some constipation 
after surgery. You have been given medication to help with this 
issue. 

 
-Wound Care: Remove the dressing in 2 days. If the incision is 
draining cover it with a new sterile dressing. If it is dry then 
you can leave the incision open to the air. Once the incision is 
completely dry (usually ___ days after the operation) you may 
take a shower. Do not soak the incision in a bath or pool. If 
the incision starts draining at anytime after surgery, do not 
get the incision wet. Cover it with a sterile dressing. Call the 
office. 
 

 
-You should resume taking your normal home medications. No 
NSAIDs.
 

 
-You have also been given Additional Medications to control your 
pain. Please allow 72 hours for refill of narcotic 
prescriptions, so please plan ahead. You can either have them 
mailed to your home or pick them up at the clinic located on 
___ 2. We are not allowed to call in or fax narcotic 
prescriptions (oxycontin, oxycodone, percocet) to your pharmacy. 
In addition, we are only allowed to write for pain medications 
for 90 days from the date of surgery.
 

 
Please call the office if you have a fever>101.5 degrees 
Fahrenheit and/or drainage from your wound.
 

Physical Therapy:
Activity as tolerated

Treatments Frequency:
Please continue to change the dressing daily
 
Followup Instructions:
___

{'fever': ['Other postoperative infection'], 'pain': ['Other postoperative infection'], 'redness': ['Other postoperative infection'], 'worsening pain': ['Other postoperative infection'], 'urinary incontinence': ['Other specified surgical operations and procedures causing abnormal patient reaction'], 'hypothyroidism': ['Postsurgical hypothyroidism'], 'mitral valve prolapse': ['Mitral valve disorders'], 'lumbar laminectomy': ['Other specified surgical operations and procedures causing abnormal patient reaction'], 'hypertension': ['Unspecified essential hypertension'], 'irritable bowel syndrome': ['Irritable bowel syndrome'], 'knee joint replacement': ['Knee joint replacement'], 'lumbago': ['Lumbago']}