Yejoo Hwang 1
4/22/2022
Biographic Data:
Name: Gloria Lewis
Birthdate: 01/02/1953 (69 yo)
Gender: female
Address: 123 14th street NY, NY 10011
Birthplace: NY, NY
Marital status: married
Race: black
Ethnic origin: African American
Occupation: unemployed
Primary language: English
Authorized representative: N/A
Source of History:
Patient and chart
Chief Complaint:
“Right knee pain wound opened up and with a lot of swelling and pain”
History of Present Illness:
Ms. Lewis is a 69 yo female with a history of osteoarthritis, total knee arthroplasty,
thrombocytopenia. During the night of 3/16, she felt a lot of swelling and pain around her right
knee. She woke up the next morning to see that her surgical site on her right knee was separated.
She went into the ED and was admitted with wound dehiscence and post op infection. Prevena
was placed on her wound, but does not complain of pain or discomfort from drainage. She was
placed in NPO and given 50mg tigecycline q12. Patient expressed that she was afraid to take
antibiotics as has many recently discovered allergies to antibiotics such as vancomycin,
daptomycin, and rifampin. However, she does not feel any signs of symptoms of allergies to the
tigecycline.
Surgical History:
S/p total knee replacement, bilateral
S/p cholecystectomy
H/O cesarean section
H/O lymph node excision
Medical History:
Rheumatoid arthritis
Thrombocytopenia
H/O blood clots
Yejoo Hwang 2
4/22/2022
Cellulitis
Osteoarthritis
Spinal stenosis
PVD
Chronic renal insufficiency
MTHFR mutation
Obesity
Edema of both lower legs
Pulmonary emboli
Mixed connective tissue disease
HTN
Asthma
Allergies:
Allergy
daptomycin → Rash
Keflex → Rives
rifampin→ other
Intolerance
NSAIDS → nephrotoxicity
vancomycin → other
Current Medication
Antibiotics
hydroxychloroquine - 200 mg PO bid - abx tx for RA
tigecycline IVPB - 50mg IV q12h infuse over 60 minutes - abx tx for post op infection
Cardio
carvedilol - 6.25 mg PO q12h - beta-blocker used for HTN
Pulm
mometasone - 220 μg inhaler1 puff qd - corticosteroid to prevent asthma attack
montelukast - 10mg PO qd - leukotriene to control and prevent asthma attack
Neuro
acetaminophen tablet - 975 mg PO q8h - pain reliever
Heme
enoxaparin injectable - 120 mg sq q12h - anticoagulant to prevent DVT
GI
cyanocobalamin - 100 μg PO qd - man made vitamin B12 for vitamin B 12 insufficiency
pantoprazole tablet - 40 mg PO before breakfast - proton-pump inhibitor for GERD tx
sucralfate - 1g PO qid - to prevent or treat gastric and duodenal ulcer
Other
Yejoo Hwang 3
4/22/2022
folic acid - 1 μg PO qd - vitamin for anemia
predniSONE tablet - 15 mg PO qd (stop after 5 days) - corticosteroid used for blood disorders
and severe allergies
PRN
ALBUTerol - 90 μg HFA inhaler 2 puffs q6H PRN bronchospasm
fluticasone propionate - 50 μg 1 spray both nostrils bid PRN nasal congestion
loratadine - 10 mg PO qd PRN itching
Cyclobenzaprine - 5 mg tid PRN muscle spasm
HYDROmorphone tablet - 4mg PO PRN pain
Family History:
HTN, obesity, RA, and MTHFR mutation
Functional Assessment:
Self-esteem, self-concept: moderate with a positive outlook in life
Activity/exercise: sedentary lifestyle with little to no daily exercise
Sleep/rest: sleeps about 8-9 hours a day and sometimes takes midday naps
Nutrition/elimination: urine 5-7 times a day and bowel once a day
Interpersonal relationships/resources: her family is a strong support system that she relies on
Spiritual resources: no religious
Coping and stress management: manages stress by watching TV
Personal habits: n/a
Alcohol: not often
Illicit or street drugs: n/a
Environment/hazards: n/a
Intimate partner violence: n/a
Perception of Health:
Patient defines health as “something you have to be blessed with”. She describes that most of her
life she was sick. Her concerns were about her future as she does not know “what is in store” for
her. Her expectations for the nurses and physicians is that they try their best to heal her.
Review of Systems:
General: Pt is sitting in a bed without distress.
Skin: Skin color normal to ethnic background, turgor good, no lesion
HEENT: hair even distribution, thick texture, no lesions or pests; eyes fields normal by
confrontation, corneal light reflex bilateral, and PERRLA; pinna skin intact with no masses,
lesions, tenderness, or discharge and external canals are clear with no redness, swelling, lesions,
foreing body, or discharge; nose symmetric, no deformity or skin lesions, nares patent, mucosa
Yejoo Hwang 4
4/22/2022
pink with no discharge or lesions; throat mucosa pink, no lesions or exudate, uvula rises in
midline on phonation, and tonsils 1+
Neck: carotids 2+ and equal bilaterally; no JVD
Breasts: symmetrical with no masses or lesions
Respiratory: breathing is easy unlabored, lung sounds clear bilaterally with no adventitious
sounds
Cardiovascular: RRR, Normal S1 and S2, No S3 or S4, No murmurs
Gastrointestinal: Soft, non-distended, non-tender and bowel sounds in all quadrants w/
normoactive
Urinary: regular voiding w/o dysuria or frequency; urine color amber and clear
Genital: no masses or lesions
Peripheral Vascular: SCD on legs with h/o PVD; edema in both legs and h/o of blood clots
Musculoskeletal: R knee swollen and with heat and tenderness; limited ROM in both legs
Psychiatric: calm and not anxious
Neurologic: AOC x3, PERRLA, CN II-XII. Grossly intact
Hematologic: denies easy bruising
Endocrine: thyroids non-palpable
Subjective:
Patient knees feel uncomfortable and legs feel heavy
Objective:
BP: 124/81
Pain level: 4
BT: 98.4
PR: 82
Oxygen Saturation: 97%
RR: 16 breaths per minute
Physical Examination:
P: Patient was admitted for a post-op infection and wound dehiscence in R knee after a TKA
with edema in both legs
I: Assessed client for pain. Client indicated R knee pain rated 9/10 to be a dull constant.
Physician ordered Prevena, HYDROmorphone 4 mg, tigecycline IVPB 50 mg q12h. Patient
rated pain 4/10 and less discomfort in her legs.
E: Patient does not express any discomfort. Assess wound and pain q4h. Provided
non-pharmacologic pain management and comfort measures.
Assessment:
Risk of Ineffective Peripheral Tissue Perfusion r/t venous stasis as evidenced by edema and
tenderness in both lower legs