Sample Name: Knee Arthroplasty - Discharge Summary
Description: Painful right knee status post total knee arthroplasty many years ago. Status post poly exchange, right knee, total knee arthroplasty.
(Medical Transcription Sample Report)
ADMISSION DIAGNOSIS: Painful right knee status post total knee arthroplasty many years ago. The patient had gradual onset of worsening soreness and pain in this knee. X-ray showed that the poly seems to be worn out significantly in this area.
DISCHARGE DIAGNOSIS: Status post poly exchange, right knee, total knee arthroplasty.
CONDITION ON DISCHARGE: Stable.
PROCEDURES PERFORMED: Poly exchange total knee, right.
CONSULTATIONS: Anesthesia managed femoral nerve block on the patient.
DISCHARGE INSTRUCTIONS AND MEDICATIONS: The patient is to be discharged home to the care of the son. Diet is regular. Activity, weight bear as tolerated right lower extremity. Continue to do physical therapy exercises. The patient will be discharged home on Coumadin 4 mg a day as the INR was 1.9 on discharge with twice weekly lab checks. Vicodin 5/500 mg take one to two tablets p.o. q.4-6h. Resume home medications. Call the office or return to the emergency room for any concerns including increased redness, swelling, drainage, fever, or any concerns regarding operation or site of incision. The patient is to follow up with Dr. ABC in two weeks.
Keywords: discharge summary, painful right knee, total knee arthroplasty, poly exchange, femoral nerve block, patellar, tibial poly, knee arthroplasty, knee, arthroplasty,