Discharge Summary
Name: Jane Doe
DOB: xx-xx-1954
Date: November 17, 2012
Date of Admission: November 13, 2012 Total Knee Replacement Surgery
Date of Discharge: November 17, 2012
Admission Diagnosis: B/L TKR
Discharge Diagnosis: B/L TKR, osteoarthritis
Discharge condition: stable
Consultations: PT – John Clark, OT – Tom Thumb, Respiratory therapist – Lois Bradshaw
Procedures: B/L TKR surgery, X-rays of B/L knees,
HPI: Patient presented to EMHS for scheduled B/L TKR surgery. Patient had history of B/L
knee pain x 10 years which has worsened over time, localized to knee joints, pain throughout the
day with activity, described as constant aching pain, pain aggravated with running, basketball
and skiing, minimally alleviated with rest and ice, 8/10 pain severity with 10/10 being broken
radius. Associated symptoms of knee edema. Denies history of rheumatoid arthritis, injury to
knees, gout.
Hospital course:
November 13, 2012 – Bilateral TKR surgery, placement of 2 Stryker Surgical Drains
November 14, 2012 – Stryker Drain removal from B/L knees
November 14, 2012 - Foley catheter removed to prevent UTI
November 16, 2012 – Discharge lab tests (most recent post-op labs)
CBC – Hgb 14.2 g/dL, Hct 45%, RBC 4.9 x 106/mL, RDW 13.2, MCV 90, MCH
28, MCHC 35%, platelet 250,000
CMP – albumin 4.8, alk phos 90 units/L, ALT 40 units/L, AST 15 units/L,
bilirubin 1.2 mg/dl, calcium 9.3 mg/dl, carbon dioxide 22 mmol/L,
chloride 101 mmol/L, creatinine 0.91 mg/dL, fasting glucose 85 mg/dL,
potassium 4.5 mmol/L, total protein 7.3 g/dL, BUN 19 mg/dL, sodium
138 mmol/L
PT/PTT INR 12.2/2.2
Discharge Physical Examination:
General – NAD, AAOx3, well-nourished, well-developed male appropriate for age.
Vitals – Ht. 68 in., Wt. on admission 169, Wt. on discharge 167, T 98.4, BP 134/86, Pulse 92,
RR 18, SaO2 100% on room air.
Head– normocephalic
Eyes - white sclera, no icterus or conjunctival injection
Mouth/Throat – MMM, membranes pink in color. No pharyngeal erythema.
Neck – Trachea midline. No masses on inspection. No carotid bruits on auscultation or
thryomegaly on palpation, carotid pulse +2/+2.
Pulmonary – Chest equally rises and falls, no asymmetry. CTA B/L, no wheezes, rales or
rhonchi on auscultation.
Cardiac – No lifts or heaves on inspection. No lifts, heaves or thrills with palpation. RRR, S1 and
S2 identified, no M/G/R or S3 or S4 on auscultation.
GI – Symmetric, non-distended abdomen, active bowel sounds x 4 quadrants, non-tender with
light/deep palpation x4 quadrants.
Musculoskeletal –Limited ROM due to knee immobilizer braces and pain. Full ROM - ankle
dorsiflexion/plantarflexion, eversion and inversion with 5/5 strength against resistance.
Extremities – Wound dressings wrapped on knees bilaterally, staples in place with no discharge
or erythema noted. Ecchymotic skin along periphery of incisions, mild non-pitting edema
localized to bilateral knees not present in ankles or feet. Bilateral knees warm to palpation.
Capillary refill < 2 seconds. No cyanosis.
Activity: weight bearing as tolerated with front-wheeled walker
Diet: Regular – no restrictions.
Discharge Meds:
1. Percocet 5/325 10 mg 1 TAB PO q6 hrs for pain
a. Side effects: dependency, hypotension, dizziness, respiratory depression, seizures,
N/V, constipation, pruritis, rash.
b. Patient educated on the risk of constipation with any narcotic medicine.
Metamucil or milk of magnesium may be used as needed if constipation persists
for more than 2-3 days without bowel movements.
2. Coumadin 2 mg PO QHS at 9 o’clock DVT prophylaxis
a. Side effects: prolonged bleeding, ecchymosis, N/V/D, weakness, headache,
dizziness, fever, rash.
3. Ibuprofen 600 mg PO 1 TAB QID x 7 days
a. Side effects: N/V, constipation, dyspepsia, fluid retention, ecchymosis, liver
toxicity.
4. Keflex 500 mg PO 1 TAB BID x 10 days for infection prophylaxis
a. Side effects: N/V/D, headache, dizziness, liver toxicity, rash.
Patient educations:
1. Infection education – patient educated on risk of infection with foreign materials used in
TKR.
a. Replacement materials are considered FB and susceptible for infection or
rejection.
b. Patient educated on symptoms of TKR rejection:
c. Advised to take Keflex as directed for 10 days for infection prevention and then to
call either Orthopaedic office or PCP on as needed basis for another prescription
if symptoms of URI, pneumonia, GI infection present
2. Inflammation education – Assure patient that knee and lower leg swelling/bruising is
normal process after surgery. Patient instructed to apply ice to knees bilaterally for 20
minutes every hour to reduce inflammation. Ibuprofen 600 mg PO 1 TAB should be
taken every 6 hours to reduce inflammation.
3. DVT education – patient instructed to wear compressive stockings throughout the day to
increase circulation in lower extremities to prevent DVT. Patient also instructed to walk
as much as possible to prevent stasis. Patient to continue Coumadin until follow-up
appointment when PT/PTT INR will be repeated to assess anticoagulation status.
4. Pain management –Percocet 5/325 10 mg PO q6 hours daily. Eventual goal is to wean
patient off of Percocet and only take as needed with pain management with OTC Tylenol
325 mg 1-2 TABS PO TID.
5. Fall management – use front wheeled walker when weight bearing and ambulating.
Avoid taking stairs until follow up. Degree of weight bearing will be dependent on
patient’s pain tolerance and ability to balance with bilateral replacement.
6. Driving – patient should not drive until after follow-up appointment and patient is able to
ambulate without wheeled walker.
7. Wound care – patient advised to keep dry dressings over incisions without adding any
lotion or cream to surrounding area. Sponge-bath washings recommended for first week
post-surgery. Showers may be taken after 1 week, avoid taking baths or going into pools
or hot tubs until staples are removed and incision has completely healed.
Follow up: Scheduled appointment November 26, 2012 to ensure no signs of infection (discharge
from incision area, fever) or complications from surgery, also address pain status.
1. Patient instructed to contact office or go straight to ED if he notices fever, significant
swelling, redness, pain, increased warmth, or discharge from the incision site.
Alyson Wattai, PA-S