Discharge Summary
Elijah Hanna PA-S
Lock Haven University PA Program
7-21-12
Name: ***** **********
MRN: ********
Race & Gender: Caucasian Male
Insurance: Geisinger Gold
Date Of Birth: 4/12/1951
Date: 7/15/2012
Admission Date: 7/12/2012
Discharge Date: 7/15/2012
Admitting Diagnosis: Right Total Knee Revision due to loosening
Discharge Diagnosis:
 Principal Discharge Diagnosis: Right Total Knee Revision
 Other Discharge Diagnoses Addressed:
1. Diabetes Mellitus Type 2
2. HTN, Goal Below 140/90
3. Hyperlipidemia, LDL Goal <70
Consultants:
 Care Management- Amy Rowan CMC
 Adult Occupational Therapy- Dan Duncan OT
 Adult Physical Therapy- James O’Brien PT
 General Internal Medicine- Amy Speeckaert MD
 Anticoagulation Clinic- John Giger MD
Procedures: Right Total Knee Revision performed by Dr. Thomas R. Bowen MD on
7/12/2012. A NexGen LPS-Flex Mobile knee replacement was placed by bone
cement in Mr. ***** ********** to replace a loose DePuy Sigma Fixed Bearing knee
replacement that was implanted on 8/3/2011. Post-operative right knee x-ray
imaging shows the revision components to be in good position. The patient was put
under general anesthesia by Dr. Zi Lang MD, and supervised by Karen Costina CRNA
with no complications. The patient had an endotracheal intubation with no
complications. The patient had a Foley catheter placement with no complications.
The patient was given 2g IV Cefazolin 1 hour prior to incision for prophylaxis. The
procedure took 100 minutes from incision to closure. The patient was stable and
ventilating without assistance 5 minutes after discontinuation of anesthesia and
endotracheal extubation. Blood loss was minimal and the patient was within normal
ranges of hemoglobin (15.8 on 7/12/2012 and 15.0 on 7/15/2012) and hematocrit
(47% on 7/12/2012 and 46% on 7/15/2012) pre-, and post-operatively.
Complications: None
History & Hospital Course:
Mr. ***** ********** is a 71 y.o. Caucasian male with a history of DJD in his
right knee. He underwent right total knee arthroplasty on 8/3/2011 by Dr. Haas in
Pottsville, PA. The surgery was done without complication, and post-operative
imaging showed good position of DePuy Sigma Fixed Bearing knee replacement.
The patient was initially was doing well and making good progress with physical
therapy in the following three months with little to no pain. However, around 6
months after the total right knee arthroplasty the patient had minimal pain (2/10)
in his right knee. He says the pain has progressively gotten worse over the last 5
months and was said to be a (7/10) that worsened with flexion and extension of his
right knee reported on 6/3/12. He also said he noticed a clicking or popping sound
and sensation in his right knee that he reported on 6/3/12. The patient could flex
and extend the knee to 90 and 10 respectively. At this same office appointment
with Dr. Thomas R. Bowen MD he was x-rayed and diagnosed with failed total right
knee replacement due to loosening of the internal components. The patient had the
necessary pre-operative office visit and joint replacement class on 6/10/2012. At
this date they completed all pre-operative requirements and were cleared for
surgery. The patient was admitted on 7/12/2012 for right total knee revision
surgery as described in the procedure above. The patient was alert and oriented x’s3
and confirmed consent to continue with the operation. The patient had no swelling
or erythema of the lower extremities with intact skin, sensation and motor control.
The patient had no post-operative complications through admission to discharge.
The patient was passing flatus and had a bowel movement the next morning after
surgery and was started on a normal diet. The patient was educated on the
discharge plan as seen below before discharge on 7/15/2012, and had no concerns
or questions.
The patient was treated for existing hypertension post-operatively (152/92
on 7/12/2012) with continuation of his previous hypertensive medications
including Diovan 80mg PO once daily, Lasix 40mg PO BID, Toprol XL 50mg PO once
daily, and Norvasc 5mg PO once daily. The patient was given serial vital sign
monitoring every hour post-operatively and was normotensive (132/82 on
7/13/2012) and (130/82 on 7/15/2012) upon discharge.
The patient was treated for existing hyperlipidemia post-operatively (LDL of
86 on 7/12/2012) with continuation of his previous hyperlipidemia medications
including Crestor 5mg PO once daily. The patient remained above the goal of LDL
<70 at discharge on 7/15/12.
The patient was treated for existing diabetes mellitus type 2 post-operatively
(HgbA1C of 8.1 on 7/12/2012 pre-operatively) with continuation of his diabetic
medications including Lantus 100 unit/mL at 20 units SQ BID. The patient never had
any hypoglycemic or hyperglycemic events throughout admission to discharge on
7/15/2012.
Discharge Plan:
 Condition Upon Discharge: A&O x’s 3 in stable condition with adequate
pain control.
 Discharged To: Home
 Treatment/Services: Patient is instructed to start, continue, and
discontinue medications as seen below. Patient will continue with in home
physical and occupational therapy until deemed unnecessary with adequate
control by PT, OT, Care Management and Dr. Thomas R. Bowen MD. Patient
will continue scheduled follow up visits with the Anticoagulation Clinic for
the next six weeks, or longer if necessary. Patient will continue follow up
visits with Orthopaedics at Geisinger Medical Center as scheduled.
 Activities: Patient is instructed to continue physical therapy exercises as
instructed by PT. The patient is told to avoid repetitive heavy lifting,
excessive stair climbing, high impact loading, quick stop-start or twisting
motions, and low seated surfaces or chairs. The patient is told to use the
ambulation assisting equipment as needed including their walker and cane.
Patient is told that they can expect to be walking without assistance by 8
weeks and should feel comfortable enough to drive a car by then, but to avoid
for now. At each visit activity level will be assessed and restrictions revised.
 Diet: Normal well-balanced diet
 Education: Patient is educated on medication use as seen below. Patient is
warned about possibility of DVT and PE and told to immediately seek
medical attention if experiencing any chest pain, shortness of breath, and leg
or thigh pain. Patient is educated that along with warfarin medication
compliance, they can help avoid such possibilities by ambulating and
exercising as instructed by PT. Patient is educated on signs of internal and
external infection including a red, hot, swollen and painful right knee joint,
and/or a red, hot, painful, discharging incision that is accompanied by fever.
The patient is told to report any of these findings to their PCP or Jane E. Bates
PA-C as soon as they are seen. Patients activity and diet education is as seen
above. Patient is given reasonable expectations of right total knee revision as
was given pre-operatively. These include hopeful cessation of right knee pain
and complete or near return of pre-operative range of motion. Patient is
educated, and understands that total knee revision implant’s duration is
variable from patient to patient. Patient is told they can facilitate bone
healing by continuing to avoid any tobacco or alcohol consumption, and
maintaining tight control of their diabetes.
 Date Of Next Appointment: 7/22/2012 with PCP Michael J. Zawisza DO, and
7/30/2012 with Orthopaedics at Geisinger Medical Center with Jane E. Bates
PA-C.
Medications At Discharge:
 Start Taking These Medications:
1. Oxycodone-Acetaminophen 5-325mg PO- 1 Tablet q4hrs PRN for pain.
Patient educated on possible side effects including lightheadedness,
dizziness and sedation and to avoid activities requiring mental
alertness and coordination like driving a motorized vehicle after
taking. Patient is educated on signs and symptoms of hepatoxicity and
told to not take any other acetaminophen containing medications like
Tylenol. Patient is educated on possibility of constipation, euphoria,
dysphoria, nausea, vomiting, pruritis, and rash and told to report any
of these side effects. Patient told to avoid alcohol consumption.
2. Warfarin Sodium 5mg PO- 1 Tablet daily (INR monitored, and dosage
changes by Anticoagulation Clinic).
Patient educated on possibility of bleeding complications and to avoid
activities in which cuts, bruising or injury is likely to occur. Told to
brush with a soft toothbrush to avoid bleeding gums. Patient told to
consume same amount of vitamin K containing foods daily. Patient
told to avoid alcohol consumption. Patient is told to take bleeding
events seriously and to seek medical attention if there are any
external or internal signs of bleeding.
3. Sennosides 8.6mg PO- 1 Tablet daily PRN for constipation.
Patient is educated that possible side effects include nausea, vomiting,
diarrhea, muscle cramps/weakness, irregular heartbeat, dizziness,
decreased urination, or mental/mood changes. The patient is told to
report these persistent changes immediately to their primary care
provider if experienced. Patient is educated that this medication can
turn the urine to a reddish/brown color and that this effect is
harmless and will discontinue when medication is stopped. If it is
persistent then they should inform their primary care provider.

Continue These Medications:
1. Crestor 5mg PO- 1 Tablet daily
2. Multivitamin PO- 1 Tablet daily
3. Lasix 40mg PO- BID
4. Diovan 80mg PO- 1 Tablet daily
5. Toprol XL 50mg PO- 1 Tablet daily
6. Lantus 100 unit/mL SQ- 20 units BID
***All continuing medications should continue to be used with the same
precautions and monitoring as the primary care provider instructed.

Stop Taking These Medications:
1. Bayer Low Strength 81mg PO- 1 Tablet daily
Issues To Be Addressed At Follow-Up:
 Right total knee revision internal components in good position on x-ray
imaging.
 Right knee pain assessment and pain medication control.
 Assessment of physical therapy progress including right knee flexion and
extension range of motion. Activity restrictions assessed.
 Assessment of incision and wound healing.
 Assessment of DVT prophylaxis and medication control.
 Assessment of bowel movements and medication control.
 Assessment of hypertension, hyperlipidemia, and diabetes mellitus type 2
medications and control.
CC:






Primary Care Provider- Michael J. Zawisza DO
523 S. Garfield Avenue, Schuylkill Haven, PA 17972
(570)-385-3826 (office)
Orthopaedics, Geisinger Medical Center- Jane E. Bates PA-C
Anticoagulation Clinic, Geisinger Medical Center- John Giger MD
Physical Therapy, Geisinger Medical Center- James O’Brien PT
Occupational Therapy, Geisinger Medical Center- Dan Duncan OT
Care Management, Geisinger Medical Center- Amy Rowan CMC
Elijah Hanna PA-S (7/15/12)