Sample Type / Medical Specialty: Consult - History and Phy.
Sample Name: Postop Medical Management
Description: Post-surgical medical management; right total knee replacement.
(Medical Transcription Sample Report)
REASON FOR CONSULTATION: Post-surgical medical management.
PROCEDURE DONE: Right total knee replacement.
1. Arthritis of the right knee.
PAST SURGICAL HISTORY: Hysterectomy, Cesarean section, left hip arthroplasty, and breast biopsy.
MEDICATIONS: Hyzaar 12.5 mg p.o. daily, Femara 2.5 mg p.o. daily, Fosamax 70 mg p.o. every week, aspirin 81 mg p.o. daily, and vitamin.
HISTORY OF PRESENT COMPLAINT: This 84-year-old patient with history of arthritis underwent right total knee replacement yesterday. The patient is admitted today to the surgical floor for postoperative management. The patient tolerated the procedure well.
REVIEW OF SYSTEMS:
CONSTITUTIONAL: No fever, chills, or malaise.
RESPIRATORY: The patient denies shortness of breath, cough, or wheezing.
CARDIOVASCULAR: No known heart problems. No orthopnea, palpitations, syncopal episode, or pedal swelling.
GASTROINTESTINAL: She denies nausea or vomiting. No history of GI bleed.
GENITOURINARY: No dysuria, no hematuria.
ENDOCRINE: Negative for diabetes or thyroid problems.
NEUROLOGICAL: No history of seizure or TIA. Cognitive function is intact.
SOCIAL HISTORY: The patient does not smoke. She consumes alcohol moderately.
FAMILY HISTORY: Positive for cancer.
GENERAL: This is an 84-year-old lady who looks young for her age.
VITAL SIGNS: Blood pressure of 138/53, pulse is 73, respiratory rate of 20, and O2 saturation is 95% on room air. She is afebrile.
HEAD AND NECK: Face is 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 is appreciated.
ABDOMEN: Soft and nontender. Bowel sounds are positive.
EXTREMITIES: There is no pedal swelling.
LABORATORY DATA: Hemoglobin has dropped from 12.6 to 10.2. Hematocrit is 30. Glucose is 125. BUN is 15.9, creatinine is 0.6, sodium is 134, and potassium is 3.8.
ASSESSMENT AND PLAN:
1. Right knee arthritis status post right total knee replacement. The patient tolerated the procedure well.
2. Anemia due to stated operative blood loss, would not require transfusion at this point.
3. Hypertension, under control. Continue current home medications.
4. Deep vein thrombosis risk, prophylaxis as per surgeon.
5. Gastrointestinal prophylaxis.
6. Debility. Continue physical therapy and occupational therapy.
Keywords: consult - history and phy., knee arthritis, status post right total knee replacement, post surgical medical management, total knee replacement, medical management, prophylaxis, therapy, arthritis, management, surgical, replacement, postop,