My patient is Robert Jones 

 White Male

0730: Orthopedic unit – surgery is delayed

Patient of Dr. Smiley

CHIEF COMPLAINT: chronic osteoarthritis to the right knee

Pain has worsened over the past couple of months despite meds.

Pain is affecting daily activities, sitting in recliner for most of the day. Waking up from sleep.

Medical: NONE

Surgical: NONE

Hospitalizations: NONE

Grandparent : Natural causes

Mother: 82 from CVA, history of HTN, HLD

Father: 80 from AMI, history of CAD, HTN

Child: 29, alive and well, NKMP

Tabacoo: half a pack a day for 32 years , quit 1 week ago

Exercise: Minimal

Immunizations: Up to date per CDC guidelines

Alert, oriented, and cooperative

Alert and oriented x4

RLE slightly limited ROM and 3/5 strength due to pain 4/10

Full ROM and muscle strength 5/5 to all other extremities

Meds:

Calcium Carbonate 600 mg PO 1AM

Meloxicam 15 mg PO qAM

0800: Diagnosis – Elective total right knee arthroplasty

Stable

Full code status

Shellfish allergy – gets a rash

NPO until after surgery

Interventions: SCDs to bilateral lower extremities

Place IV x 1

Labs:

BMP, CBC, Blood type and cross, PT/INR (Done pre-op)

Consult:

Physical and Occupational therapy to evaluate and treat

Social work for discharge planning

“My knee still hurts, but this pain in my calf is new.”

No tingling or numbness in calves.

Constant pain. Calf pain 8/10

Deep inside pain not superficial

“It’s like a bad cramp”

Ibuprofen last night (treatment for pain in calves)

Knee pain has been getting worse over time and constant

Inflammation in right knee

Pain med & recliner ease pain in the knee

Knee pain 5/10, dull ache with some sharpness

Knee pain was on and off

Childhood illnesses: usual coughs, cold, tummy aches

A few beers in the weekend

Drinks coffee – almost 3 cups in morning

“Normal amount” of water/fluids in a day

“Can’t get around like I used to”

Vitals

SKIN: warm, dry

5’9 184lb(84.0 kg)

Temp: 98.6 F

Pulse : 70

Respiration: 25

BP: 122/76

SP02: 98%

BMI 27.2