60-Year-Old Man S/P 12/8 Right Total Hip Arthroplasty

ID/CC: 60-year-old man s/p 12/8 right total hip arthroplasty.

HPI Mr. Smith is a 75-year-old man with no significant medical history other than right hip arthritis, who underwent right total hip replacement on 12/8/05. Prior to surgery pt had progressive right hip pain for approximately 8 years. Pt does not recall any history of trauma, but does remember his right hip "giving out" while serving in the Coast Guard in 1995. X-rays prior to surgery showed severe degenerative joint disease in his right hip.

Post-op course was uncomplicated. Incision was C/D/I day of discharge per ortho.

He will follow up with orthopedic surgery on December 21st for wound evaluation and staple removal.

Activity: WBAT

Diet: Regular 1800

PAST MEDICAL HISTORY: 1. Right hip DJD

PAST SURGICAL HISTORY: 1.

ALLERGIES: NKDA

Meds on transfer: Diclofenac 75mg, BID Promethazine 12.5mg, Q6hr, PRN Ascorbic Acid 250mg, BID Maalox Colace 240mg, BID FESO4 325mg, TID MVI One tab, QD Enoxaparin 40mg/0.4ml, SC QD Vicodin 2 tabs, Q 4 hours Oxycodone 10mg po q6 hours Benedryl 25mg, QHS, PRN, Insomnia Dulcolax Supp. 10mg, PR, QD, PRN Tylenol 650mg, PO/PR, Q 4 hrs, PRN

SOCIAL HISTORY: Occupation: Living situation:

Tobacco: Alcohol: Illicit drugs: N

FAMILY HISTORY:

PRIOR FUNCTIONAL LEVEL:

PATIENT & FAMILY GOALS:

ROS: Negative in all systems.

EXAM: VS T=96.7 BP=129/89 HR=68 RR=18 O2=97% RA General - Awake, Alert Hawaiian gentleman, NAD HEENT - PERRL, EOMI Resp - CTA (b) CV - RRR, nl S1/S2 no MRG Abd - soft, obese, ND, NT, NABS. No organomegaly. Ext - DP 2+ Bilaterally. Incision site: C/D/I

Neuro Exam: Mental status: Alert and oriented x3. Cooperates 100% with exam. Fluent speech and comprehension

Cranial nerves: II- XII grossly intact Strength: AB EF WE EE FF IOM HF KE KF DF EHL PF Left 5 5 5 5 5 5 5 5 5 5 5 5 Right 5 5 5 5 5 5 NT NT NT 5 5 5

Abreviations: AB: shoulder abductors; EF elbow flexors; WE wrist extensors; EE elbow extensors; FF finger flexors; IOM interosseous muscles; HF hip flexors; KE knee extensors; DF dorsiflexors; EHL extensor hallicus longus; PF plantarflexors; NT not tested because of pain at B KJ's

Light touch and proprioception intact all extremities

Coordination: Fine finger tap, finger-nose-finger normal coordination and speed for age without resting or intention tremors.

Assessment: 60yo s/p Right THA due to degenerative joint disease on 12/8/05 ready for acute rehabilitation.

Problem list and plan:

1. Impaired mobility and self care. Comprehensive intensive multidisciplinary rehabilitation with PT for mobility, strengthening and endurance and OT for safe ADL's and range of motion. Goals include modified I mobility and self-care and preservation of full AROM hip flexion and extension.

2. Pain. PRN acetaminophen is enough per patient. Will continue to access and adjust as necessary.

3. S/p R. Total hip replacement: Aggressive mobilization of operated hip to within limits of hip precautions to preserve range of motion. Compression stocking. Bacitracin and dry dressing to wound. Staples Clinic appointment 12/21/05.

4. Constipation. PRN Colace

5. DVT prophylaxis - lovenox for 10days (DC date 12/18).

6. Anemia - will continue the patient on FESO4 and Vitamin C for better Iron absorption.

7. Dispo - pt will go home to Hawaii with his wife when deemed appropriate by the interdisciplinary staff

RESIDENT SUPERVISION: The patient was seen and discussed in detail with Dr. Scott, Attending physician, who agrees with the assessment, treatment and plan of care.