Quality Enhancement Paper
CHIEF COMPLAINT: chronic osteoarthritis to the right knee
Pain has worsened over the past couple of months despite meds.
Pain is affecting daily activities, sitting in recliner for most of the day. Waking up from sleep.
Medical: NONE
Surgical: NONE
Hospitalizations: NONE
Grandparent : Natural causes
Mother: 82 from CVA, history of HTN, HLD
Father: 80 from AMI, history of CAD, HTN
Child: 29, alive and well, NKMP
Tabacoo: half a pack a day for 32 years , quit 1 week ago
Exercise: Minimal
Immunizations: Up to date per CDC guidelines
Alert, oriented, and cooperative
Alert and oriented x4
RLE slightly limited ROM and 3/5 strength due to pain 4/10
Full ROM and muscle strength 5/5 to all other extremities
Meds:
Calcium Carbonate 600 mg PO 1AM
Meloxicam 15 mg PO qAM
0800: Diagnosis – Elective total right knee arthroplasty
Stable
Full code status
Shellfish allergy – gets a rash
NPO until after surgery
Interventions: SCDs to bilateral lower extremities
Place IV x 1
Labs:
BMP, CBC, Blood type and cross, PT/INR (Done pre-op)
Consult:
Physical and Occupational therapy to evaluate and treat
Social work for discharge planning
“My knee still hurts, but this pain in my calf is new.”
No tingling or numbness in calves.
Constant pain. Calf pain 8/10
Deep inside pain not superficial
“It’s like a bad cramp”
Ibuprofen last night (treatment for pain in calves)
Knee pain has been getting worse over time and constant
Inflammation in right knee
Pain med & recliner ease pain in the knee
Knee pain 5/10, dull ache with some sharpness
Knee pain was on and off
Childhood illnesses: usual coughs, cold, tummy aches
A few beers in the weekend
Drinks coffee – almost 3 cups in morning
“Normal amount” of water/fluids in a day
“Can’t get around like I used to”
Vitals
SKIN: warm, dry
5’9 184lb(84.0 kg)
Temp: 98.6 F
Pulse : 70
Respiration: 25
BP: 122/76
SP02: 98%
BMI 27.2
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