Physical Exam: Vital Signs, General, HEENT Exam.

Published: 2022-12-26 18:22:23
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Physical Examination:

Vital Signs: 95% O2 saturation on room air, respiratory rate 20, pulse 70, blood pressure 127/72, Temperature 96.5.

General: Besides the aforementioned complains about the right knee section, which he complains is at the center position, the patient showed no acute distress during the time the exam was being carried out.

Heent: Tongue is in the midline without any thrush evidence. Dentition is in good repair. Sclerae nonicteric. Normocephalic.

Neck: Trachea is in the midline - no enlargement of the thyroid.

Lungs: Clear to auscultation.

Heart: Normal S1 and S2. Regular rhythm and rate.

Abdomen: No organomegaly. Soft, nondistended and nontender.

Extremities: the incision made on the right knee is intact. The steri-strip are in place. There is some reduced ecchymosis. The right knee has some diffused edema. The calf has no bilateral tenderness. The pedal pulses show bilaterally palpable.

Mental Status: during the interview as well as the exam, the patient seemed a bit anxious. Nevertheless, she was oriented and alert.

Discharge Diagnoses:

Hypothyroidism

Hypertension

Anxiety disorder

Insomnia secondary to anxiety postoperatively and pain

Postoperative constipation

Morton neuroma bilaterally of the feet

Status after the right total knee replacement secondary to the degenerative joint disease

Contact dermatitis

Distant history of migraine headaches

Gastroesophageal reflux disease

Instructions Provided to the Patient during Discharge

The advice provided to the patient was to continue taking the following medications (Miller et al., 2018): Toprol-XL 50 mg daily, Ativan 0.25 mg b.i.d. for two weeks, Percocet 5/325 mg one to two tablets q.6h. To be used p.r.n. for breaking through the pain, Celebrex 200 mg daily, for one month, trazodone 50 mg p.o. at bedtime p.r.n. for two weeks, Colace 100 mg b.i.d. for one month, Diprosone cream 0.05% cream b.i.d. to the right abdomen and the right arm, Protonix 40 mg b.i.d. for one month, oxycodone SR 20 mg p.o. q.12h. For five days, then reduce to oxycodone SR 10 mg p.o. q.12h. For five another days Synthroid 137 mcg daily.

In addition to those, the patient is advised to take Coumadin. The doses of this medicine will be adjusted per the INRs. The latter will be obtained every Thursday and Monday with the doctor receiving the results through the email or the fax. Currently, the patient is required to take Coumadin 7 mg daily (Poudel et al., 2017). The patient is further needed to remain under the use of Coumadin for 30 days. The patient needs to obtain the INR after the 30 days end. After this, the dose of Coumadin will be changed. In this discharge summary, there should be a dictation of the addendum.

Lastly, the patient needs to follow up with his appointment with the doctor in the afternoon as provided. The patient is also recommended to follow up with her primary physician. As mentioned, the patient will be discharged in four days after his condition stabilizes and improves since his status post right total knee replacement. He has also made good progress in her rehabilitation and therapies.

References

Miller, A. J., Stimac, J. D., Smith, L. S., Feher, A. W., Yakkanti, M. R., & Malkani, A. L. (2018). Results of cemented vs. cementless primary total knee arthroplasty using the same implant design. The Journal of Arthroplasty, 33(4), 1089-1093.

Poudel, D. R., Ghimire, S., Dhital, R., Forman, D. A., & Warkentin, T. E. (2017). Spontaneous HIT syndrome post-knee replacement surgery with delayed recovery of thrombocytopenia: a case report and literature review. Platelets, 28(6), 614-620.

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