DATE OF CONSULTATION: MM/DD/YYYY
REQUESTING PHYSICIAN: John Doe, MD
REASON FOR CONSULTATION: Left total hip arthroplasty.
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old right-handed woman with history of osteoarthritis of both hips, left side worse than right, with increasing pain and decreased ability to ambulate. The patient was admitted to the hospital, and she underwent a left total hip arthroplasty. There have been no postoperative complications. She is getting fairly good pain relief with her medications. She is starting to eat. She did not sleep that well last night.
PAST MEDICAL HISTORY: Osteoarthritis of the right hip. No major medical problems. Tonsillectomy as a child. D&C as a teenager.
ALLERGIES: NONE.
MEDICATIONS: Metamucil one package daily with water, OxyContin 10 mg q. 12 hours, Coumadin 5 mg daily, and oxycodone IR 5 mg q. 3 hours p.r.n. for pain.
MEDICATIONS PRIOR TO ADMISSION: Naprosyn, which she had not taken for 10 days prior to surgery, Prevacid p.r.n., calcium, glucosamine, Tylenol, vitamin C, and vitamin E.
DIET: Advance as tolerated.
FUNCTIONAL STATUS: The patient has a Foley catheter. Her last bowel movement was yesterday before her surgery. She requires setup for feeding. She requires setup for grooming from the seated position. She requires assistance for dressing, bathing, and toileting. She requires assistance for bed mobility, transfers, and ambulation. She was ambulating without assistive device prior to admission.
SOCIAL HISTORY: The patient is married. The patient works part time. She does not smoke. She does not drink. She lives in a two-level home with 14 stairs up to the bedroom and full bathroom. There is a small bathroom on the first floor.
FAMILY HISTORY: The patient’s mother died from a stroke at the age of 86. Her father is alive in his 90s. She has breast cancer.
REVIEW OF SYSTEMS: Per the HPI and PMH. She is hard of hearing bilaterally. She has a hearing aid on the left. She wears glasses. Hepatitis, possibly due to hormone replacement therapy, which was stopped.
PHYSICAL EXAMINATION:
VITAL SIGNS: Temperature 98.4, pulse 84, respirations 16, and blood pressure 112/60. Height 5 feet. Weight is 130 pounds.
GENERAL APPEARANCE: A well-developed, well-nourished woman who is in no acute distress. Her affect is normal. Her husband was present during the interview on examination.
HEENT: NC/AT.
NECK: Without bruits.
LUNGS: Clear.
HEART: Regular rate and rhythm without murmur.
ABDOMEN: Bowel sounds are positive, soft, nontender, and nondistended.
EXTREMITIES: No clubbing, cyanosis, or edema. No calf erythema, warmth, or tenderness. Peripheral pulses are strong and symmetrical. Passive range of motion was within functional limits throughout, except not tested at the left hip. The surgical incision was dressed and it was not inspected.
NEUROLOGICAL EXAMINATION: The patient is alert and oriented x3. She did not demonstrate any gross cognitive or language deficits. Cranial nerves II through XII were intact, except she was hard of hearing bilaterally. Tone was normal. No atrophy was noted. Strength was normal in all four extremities, except for 3/5 at the left hip and knee. Sensory exam was grossly intact. Coordination was intact in the upper extremities. Ambulation was not tested at this time.
LABORATORY DATA: Hemoglobin 9.4, sodium 130, potassium 3.6, and INR 1.02. Preoperative hemoglobin was 12.9.
ASSESSMENT:
1. Left total hip arthroplasty.
2. Osteoarthritis of the right hip.
3. Impaired mobility and self-care.
4. Postoperative anemia.
5. Hyponatremia.
6. Hard of hearing bilaterally.
PLAN: Physical and occupational therapies are pending. The patient is appropriate for some type of rehabilitation, as she has many stairs to negotiate at home. Her Foley catheter will be removed per orthopedic protocol. The assessment and recommendations were discussed with the patient’s husband.
