Inpatient Hip Replacement chart - H&P

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Procedure Information:

Pre-Op Diagnosis Codes:

   * OSTEOARTHRITIS OF RIGHT HIP

Procedure(s) with comments:

HIP REPLACEMENT ANTERIOR APPROACH TOTAL - HANA table

Big C-arm #2 on opposite side of table

Total hip 1, anterior hip set, Depuy add ons

Gripper x 1, Drain bag

Depuy Pinnacle cup, Actis stem, Corail for back-up

Requested Anesthetic type:  Spinal

 

I contacted patient and confirmed that I was speaking to the correct person.

 

Patient expressed understanding and agreed to proceed with the video visit and treatment if necessary. Consent documented in visit navigator. Connection was successful.

 

Chief Complaint and History of Present Illness:

XXX is a 72 Y female with a history of R hip OA for which she is scheduled for surgery.

 

Patient Active Problem List

  OSTEOARTHRITIS OF RIGHT HIP

          Added automatically from request for surgery

          1225017

 

  HYPERLIPIDEMIA

 

  ANOSMIA

 

  SENILE PURPURA

 

  ESOPHAGEAL SPASM

 

  HX OF ABNL PAP SMEAR

 HX of CIS diagnosed and treated in 1984

 

  HX OF COLONOSCOPY

          Mod to severe diverticula, repeat screening 6-2023

 

  DIVERTICULOSIS OF COLON

 

  HX OF SKIN CANCER

 

  LUMBOSACRAL RADICULOPATHY

 

  ACTINIC KERATOSIS

 

  HTN (HYPERTENSION)

 

  ASTHMA

 

 

Resolved Hospital Problems

No resolved problems to display.

 

Past Surgical History:

Procedure           Laterality             Date

•             CONE BIOPSY OF CERVIX                                

                for CIS 1984

 

Allergies

Allergen               Reactions

•             Co-Trimoxazole  

                                rash

•             Codeine                

                                swelling

•             Hydrocodone-Acetaminophen    

                                upset stomach.; tylenol is ok

•             Nsaids, Non-Selective [Non-Steroidal Anti-Inflammatory Agents] Renal Toxicity

                                Cr increased to 1.78 after several days of PO Toradol.

•             Prochlorperazine              

                                hospitalization

 

Tobacco Use

•             Smoking status: Never Smoker

•             Smokeless tobacco:        Never Used

Vaping Use

•             Vaping Use:        Never used

Substance Use Topics

•             Alcohol use:       No

                                Alcohol/week:  0.0 standard drinks

•             Drug use:             No

 

 

E-Cigarettes/Vaping

                Questions           Responses

                E-Cigarette/Vaping Use Never User

 

 

Social History

 

Substance and Sexual Activity

Drug Use             No 

 

Family History: non-contributory

 

Family History of Anesthesia Complications: Unknown

 

Personal History of Anesthesia Complications: none

 

Review of Systems:

General: Denies fever, chills, weight change, fatigue and weakness

Cardiovascular: Denies chest pain, orthopnea and palpitations with exercise or at rest

Respiratory: Denies recent SOB and cough (productive)

Neuro: Denies fainting, seizures and headaches Falls: no, Delirium: no, Assistive devices: uses a cane sometimes

GI: Denies GERD

GU: Denies dysuria, frequency and urgency

Heme: Denies bleeding but has easy bruising

Musculoskeletal: Denies joint pain and decreased ROM neck

Skin: Denies rashes and skin changes over the surgical site

Other: none

Has the patient had a positive COVID test in the last 7 weeks? no

Has the patient had a COVID test ordered ? yes

 

Physical Exam:

General appearance: alert, well appearing, and in no distress

Neck: normal range of motion

Respiratory: no respiratory distress

Mental status: alert, oriented to person, place, and time, normal mood, behavior, speech, dress, motor activity, and thought processes

 

Most recent information from chart review:

Estimated body mass index is 25.06 kg/m² as calculated from the following:

  Height as of 3/31/22: 1.626 m (5' 4").

  Weight as of 3/31/22: 66.2 kg (146 lb).

SpO2 Readings from Last 3 Encounters:

03/31/22              98%

10/11/18              98%

02/27/18              95%

 

BP Readings from Last 3 Encounters:

03/31/22              138/72

07/06/21              135/75

06/17/21              140/76

 

Pulse Readings from Last 3 Encounters:

03/31/22              106

07/06/21              95

06/17/21              98

 

Temp Readings from Last 3 Encounters:

03/31/22              99 °F (37.2 °C) (Temporal)

07/06/21              98.3 °F (36.8 °C) (Temporal)

01/28/20              99.5 °F (37.5 °C) (Tympanic)

 

 

Pre-Operative Screening

 

Pregnancy Testing:

N/A (male, nonmenstruating female, hx of hysterectomy)

 

Obstructive Sleep Apnea Criteria:

None

 

Exercise/Functional Capacity:

4-6 mets: e.g. Yard work, climb a flight of stairs, walk up a hill and Patient's current level of activity includes the following: Up until recently was able to walk to the gym and exercise a bit 2-3 times per week.  Limited by hip pain, no SOB

 

History of Cardiac Stent: No           

 

Objections To Blood Transfusions: NO

 

Review of Other Relevant Data:

EKG: date 2018, result

Baseline artifact is present

Sinus tachycardia

RSR' in V1 or V2, probably normal variant

Right axis deviation

Nonspecific ST-T wave changes.

Compared with previous tracing no significant

change.

 

Echo: none

No results found for this or any previous visit (from the past 4320 hour(s)).

 

Cardiac Stress Test: none

 

Patient Class: Hospital Ambulatory Surgery

 

Pneumonia Prevention Education: N/A, hospital ambulatory surgery

 

Life Care Planning:

Medical Decision Maker? Patient provided information today--Tim Molinare (listed as emergency contact)

Advanced Directive? no

 

Assessment and Plan:

XXX is a 72 Y female is optimized for planned surgery.

Preliminary ASA Class: 2

The following studies have been ordered or are pending at the time of this visit: EKG to be done in pre-op

 

Patient Active Hospital Problem List:

 OSTEOARTHRITIS OF RIGHT HIP

  Assessment: Noted

  Plan:

- Operative plan per orthopedist

- No further pre-op testing indicated, but will get ECG in pre-op for new baseline.

- Recommend post-op DVT prophylaxis with ASA 81 mg BID for 4 weeks.

- Med holds as below

 

 HTN (HYPERTENSION)

  Assessment: Noted

  Plan:

- Hold HCTZ and losartan on DOS

 

 ESOPHAGEAL SPASM

  Assessment: Diet-controlled, has not used NTG in years

  Plan:

- OUtpatient fup

 

 HYPERLIPIDEMIA

  Assessment: Never started statin.

Plan:

-F/up with PCP

 

 

Patient Instructions:

The patient was provided the following PREOPERATIVE instructions:

 

PRIOR TO SURGERY

Stop all non-prescription vitamins, herbs, and supplements 1 week before surgery.

Continue all of your regularly scheduled medications

 

DAY OF SURGERY

Do not take your blood pressure medications (Hydrochlorothize and losartan) on the morning of surgery.