Sample Type / Medical Specialty: Consult - History and Phy.
Sample Name: Orthopedic Consult
Description: Medical management, status post left total knee arthroplasty.
(Medical Transcription Sample Report)
REASON FOR CONSULT: Medical management, status post left total knee arthroplasty.
PAST MEDICAL HISTORY:
4. Borderline hypertension.
PAST SURGICAL HISTORY: Hernia repair, resection of tumor, right thumb arthrodesis, carpal tunnel decompression, bilateral hip replacement, right total knee replacement about 2 months ago, open reduction of left elbow fracture.
REVIEW OF SYSTEMS:
CONSTITUTIONAL SYMPTOMS: No fever or recent general malaise.
ENT: Not remarkable.
RESPIRATORY: No cough or shortness of breath.
CARDIOVASCULAR: The patient denies any heart problems. No orthopnea. No palpitations. No syncopal episodes.
GASTROINTESTINAL: No nausea. No vomiting. No history of GI bleed.
GENITOURINARY: No dysuria, no hematuria.
ENDOCRINE: The patient is status post pituitary tumor resection and is on supplemental hormone.
MEDICATIONS: Depo-Testosterone 200 mg IM q.3 weekly, prednisone 1 tablet p.o. daily, octreotide IM on a monthly basis, morphine extended release 50 mg p.o. b.i.d., Synthroid 100 mcg p.o. daily, desmopressin 1 tablet p.o. every bedtime, aspirin/oxycodone on a p.r.n. basis, aspirin on p.r.n. basis.
ALLERGIES: IBUPROFEN AND TYLENOL.
SOCIAL HISTORY: The patient does not smoke nor drink alcohol.
FAMILY HISTORY: Noncontributory.
GENERAL: Obese, 57-year-old gentleman, not in acute distress.
VITAL SIGNS: Blood pressure of 105/55, pulse is 90. He is afebrile. O2 saturation is 95% on room air.
HEAD AND NECK: Face symmetrical. Cranial nerves are intact. No distended neck veins. No palpable neck masses.
CHEST: Clear to auscultation. No wheezing. No crepitations.
CARDIOVASCULAR: First and second heart sounds were heard. No murmur was appreciated.
EXTREMITIES: The left knee is in closed dressing. The lower extremities are still numb from spinal anesthesia.
ASSESSMENT AND PLAN:
1. Polyarthritis, status post left total knee replacement. The patient tolerated the procedure well.
2. Acromegaly, status post pituitary resection. Continue supplemental hormones.
3. Borderline hypertension, blood pressure is under control with monitoring.
4. Deep venous thrombosis prophylaxis as per surgeon.
5. Anemia due to repeated blood loss with monitor hemoglobin and hematocrit.
Keywords: consult - history and phy., polyarthritis, acromegaly, total knee arthroplasty, total knee replacement, medical management, blood pressure, arthroplasty, knee, orthopedic,