case9discharge
DISCHARGE SUMMARY
Patient Name: Marilyn Sue Stone
Patient ID: 116588 DOB: 1/24/---- Age: 50 Sex: F
Date of Admission: 02/07/----
Date of Discharge: 02/10/----
Admitting Physician: Jesse D. Smith, MD, Orthopedic Surgery
Procedures Performed: Right total hip replacement.
Complications: None.
Discharge Diagnosis: Failed total hip.
CHIEF COMPLAINT: Pain in right hip.
HISTORY OF PRESENT ILLNESS: This is a 50-year-old female with a long history of bilateral hip disease. She was born with arthrogryposis. She had a right total hip replacement done about 28 years ago. She is admitted now because of x-ray evidence of loosening of the right femoral implant and pain with ambulation.
PHYSICAL EXAM: Limited to musculoskeletal system: The right leg is 1/4" short. She has external rotation fixed at 25 degrees, internal rotation of zero degrees, abduction 10 degrees. She has pain with all these ranges of motion.
DIAGNOSTIC DATA: Laboratory: The patient's preoperative laboratory evaluation was done as an outpatient. It was all within normal limits. Cultures of her hip showed no growth. Urinalysis showed no growth. Her post-operative electrolytes showed a slightly decreased sodium of 132 due to dilution. Her hemoglobin was 10.9, hematocrit 32.2, with a white count of 10,300. The protime was 13.5 with an INR of 1.1. On the second post-operative day, her hemoglobin was 9.2, hematocrit 26.5 with a white count of 10,000 and protime of 24 with an INR of 2.1.
HOSPITAL COURSE: The patient was admitted to the hospital and the day
(Continued)
DISCHARGE SUMMARY
Patient Name: Marilyn Sue Stone
Patient ID: 116588
Date of Discharge: 02/10/----
Page 2
after admission, she underwent a right total hip replacement revision. Postoperatively she did well. Her drain was removed on the fourth postoperative day. She was transferred to the skilled nursing facility at Quali-Care Clinic for continued care and rehabilitation.
SURGICAL PROCEDURE:
Patient Name: Marilyn Sue Stone
Patient ID: 116588 DOB: 1/24/---- Age: 50 Sex: F
Date of Admission: 02/07/----
Date of Discharge: 02/10/----
Admitting Physician: Jesse D. Smith, MD, Orthopedic Surgery
Procedures Performed: Right total hip replacement.
Complications: None.
Discharge Diagnosis: Failed total hip.
CHIEF COMPLAINT: Pain in right hip.
HISTORY OF PRESENT ILLNESS: This is a 50-year-old female with a long history of bilateral hip disease. She was born with arthrogryposis. She had a right total hip replacement done about 28 years ago. She is admitted now because of x-ray evidence of loosening of the right femoral implant and pain with ambulation.
PHYSICAL EXAM: Limited to musculoskeletal system: The right leg is 1/4" short. She has external rotation fixed at 25 degrees, internal rotation of zero degrees, abduction 10 degrees. She has pain with all these ranges of motion.
DIAGNOSTIC DATA: Laboratory: The patient's preoperative laboratory evaluation was done as an outpatient. It was all within normal limits. Cultures of her hip showed no growth. Urinalysis showed no growth. Her post-operative electrolytes showed a slightly decreased sodium of 132 due to dilution. Her hemoglobin was 10.9, hematocrit 32.2, with a white count of 10,300. The protime was 13.5 with an INR of 1.1. On the second post-operative day, her hemoglobin was 9.2, hematocrit 26.5 with a white count of 10,000 and protime of 24 with an INR of 2.1.
HOSPITAL COURSE: The patient was admitted to the hospital and the day
(Continued)
DISCHARGE SUMMARY
Patient Name: Marilyn Sue Stone
Patient ID: 116588
Date of Discharge: 02/10/----
Page 2
after admission, she underwent a right total hip replacement revision. Postoperatively she did well. Her drain was removed on the fourth postoperative day. She was transferred to the skilled nursing facility at Quali-Care Clinic for continued care and rehabilitation.
SURGICAL PROCEDURE: