DATE OF ADMISSION: MM/DD/YYYY
DATE OF DISCHARGE: MM/DD/YYYY
DISCHARGE DIAGNOSES:
1. Status post left total knee arthroplasty.
2. Hypertension.
3. Hypercholesterolemia.
4. Contusion, left leg.
BRIEF HISTORY: This is a (XX)-year-old female with a three- to four-year history of degenerative joint disease of the left knee with a profound exacerbation of her symptoms two months prior to admission. She recently underwent total knee arthroplasty by Dr. John Doe, and two days following her surgery, she was transferred for inpatient rehabilitation. Her immediate postoperative period was complicated somewhat by mild confusion, which seems to have at least partially resolved.
The patient has a multi-year history of hypertension, which is said to be well controlled. She has a history of hypercholesterolemia of unknown duration. Based on medications to be outlined, we questioned the patient about coronary artery disease, but she denies any history of heart disease. She was placed on low-dose Lanoxin many years ago as well as low-dose hydrochlorothiazide and has been getting continuous refills on the agents ever since then, but she is not sure why she takes them.
PAST SURGICAL HISTORY: Includes a hysterectomy, cataract extractions, and recent knee surgery.
HOME MEDICATIONS: Include Lanoxin 0.125 mg daily, HCTZ 12.5 mg daily, Benicar 20 mg daily, Zocor 80 mg daily, Lortab 5 mg q. 3 to 4 hours when necessary for pain.
ALLERGIES: None.
SOCIAL HISTORY: The patient neither smokes nor drinks. She lives by herself but sister lives next door.
FAMILY HISTORY: Positive for coronary artery disease, hypertension, and diabetes mellitus.
PHYSICAL EXAMINATION: GENERAL: The patient is a well-developed elderly Hispanic female who was oriented to time, place, and person but at times would give us the sense that she was mildly confused. CHEST: Clear. HEART: She has a regular rhythm with a rate of 75 to 80. ABDOMEN: Unremarkable. EXTREMITIES: Left lower extremity examination shows an anterior incision over the anterior aspect of the left knee, which is in the early stages of healing. Diffuse mild soft tissue swelling is present above the left knee. Subcuticular hematoma was present lateral to the patient’s incision. Distally, she has a contusion over the pretibial area of the lower extremity just above the left ankle, and she indicates that her walker fell on this area during the course of her hospitalization, striking her over the anterior pretibial area. Exam of the remaining extremities shows the patient has multiple subcuticular hematomas, varying size and age, with the patient indicating that she bleeds quite easily.
HOSPITAL COURSE: The patient was admitted for an inpatient rehabilitation program designed to increase her strength, endurance, knee range of motion, ADLs, wound management, and transfers. Additionally, safety issues were to be addressed to the patient on an ongoing basis.
The night following, the patient was transferred. She appeared to have manifestations of mild confusion, but this resolved thereafter and did not recur. The patient continued to improve throughout the course of her hospitalization, but she persisted having some 1 to 2+ swelling about the left knee. Range of motion of her knee was from 0-90 degrees at the time of discharge.
At the time of discharge, she was moderately independent with regard to all of her functions, including dressing, bathing, toileting, transfers, and ADLs, and she could ambulate 150 feet at a time with a walker. She was discharged to be followed up by Dr. John Doe.
LABORATORY DATA: Hemoglobin 9.6, hematocrit 28.2, and white count 7800. Urinalysis showed 5-10 wbc’s and a subsequent culture grew out 10,000 colonies of gram-negative rods x2, probably contaminants. Chemistries show mild elevation of creatinine to 1.6 and BUN to 31.
DISCHARGE EQUIPMENT: A 3-in-1 bedside commode, transfer tub bench, rolling walker, and a home CPM.
DISCHARGE MEDICATIONS: Lanoxin 0.125 mg daily, hydrochlorothiazide 12.5 mg daily, Benicar 20 mg daily, Zocor 80 mg daily, Lortab q. 3 to 4 hours p.r.n. pain, and Darvocet-N 100 q. 4 hours for lesser pain.
