Inpatient Hip Replacement chart - Progress notes

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PROGRESS NOTES

Relevant Medical Problems:

OSA Risk:  no

Does pt use CPAP: no

Other Concerns Identified in PREOP H&P

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.

Assessment/Plan: XXX is a 72 Y female POD #0  Right Total Hip Arthroplasty (Direct Anterior Approach)

 

planned for same day discharge if meets all criteria and medically stable

 -Wound care:

            Keep dressing clean dry and intact. 

             Can shower over dressing. Keep surgical dressing on for 7 days then can remove and can let running water go over the incision when needed, then pat it dry.

            No Staples to remove

            No drain

           

-Activities:

            WBAT,  FROM ; no hip precautions

            PHYSICAL THERAPY eval

 

-Heme:

-Pain Control:

            Per PACU protocol, if admitted then

            IV Tylenol & Toradol 

            Oxycodone 5mg q4h prn

            Adductor Canal Catheter for Knee

           

-ID:

            IV Antibiotic: Ancef 2 gm before d/c today. If admitted can administer one more dose 8 hours after last dose

            Cx: none

 

-Resp:

            Encourage IS, Home with device

            Wean down O2 as able

            OSA Protocol if admitted:

 

-GI/GU:

            No foley

            Senna/Miralax

 

-Diet:

            Regular

 

-Dispo:

            Home with Home Health if meets Same Day Home Recovery Criteria or otherwise Sunrise Discharge

 

 

Foley - no foley

Antibiotics - prophylaxis x 24 hrs if admitted

DVT prophylaxis - Start/continue pharmacologic prophylaxis 

Beta Blockers - not indicated

 

Inpatient care for this patient is medically necessary if admitted to monitor for: adequate pain control and response to medication and/or adjustments, postop care and treatment with: IV pain medication, IV antibiotics, medication titration and physical therapy