Rehab Facility, Comprehensive
Post op knee pain, confusion
OVERVIEW: JC is an 81 y/o female, admitted for PT/OT rehab post LTKA. Had a LTHA done 6 wks ago and was at NH for that rehab.
CC: #1 LTKA with acute pain and impaired mobility. “It feels like there is a fever in there (L-knee).” Unable to flex. Grimacing in pain when leg touched. RPT reports that client had more limited movement in PT today than yesterday.
Note: Hx and ROS difficulty to get due to some confusion. JC’s recent pre-op H&P notes no dementia but positive for personality disorder. I found that she had deficits in serial 7s, clock face, drawing sample figure, and phrase meaning. I don’t think she really understood who I was or the reason I was visiting with her, as I had to reorient her several times. Despite being alert and oriented x3. She acted as though my visit was a social one and insisted I stay and have lunch with her several times.
PAST HISTORY: Our conversation was not productive in this area.
Childhood: None.
From chart (Adult): MI, HTN, Hypothyroidism.
Accidents/Injury: Fall with LTHA (12-14 yrs ago?)
Operations/Hospitalizations: LTHAx2, most recent revision 6 wks ago. LTKA 2/10.
Psych: Personality disorder.
CURRENT HISTORY:
Allergies: None known.
Drug/food intol: None known.
Immunizations: No record/recall.
Screening Tests: ECG.
Environment/Safety: Uses WC, has walker but requires assist of 1 for transfers, call bell in reach, states “OK, yes, I know how to use it” but would not demonstrate call light use.
Diet: Eats 3-9 meals/day: grains, vegetables, fruits, little meat, drinks prune juice q am.
Sleep: No problems.
Activity/Exercise: Minimal, watches TV at home, fear of falling.
Habits: None
Current Medications:
Caftan 500mg, po, bid x 7 day, then to 250mg bid.
Atenolol 50mg po qd
Levothyroid 0.125mg qd
FeSO4 300mg bid x 3 wks
Trazodoue 30mg prn
ES Tylenol 1-2 q3-4 hr prn
Tyl #3 1q3-4 hr prn
Albuterol Neb bid x 5d (2.5mg/3ml)
CPM 10-15 (Can hold until PT ? with arthop concerns?), warm moist pack (L) knee 2 hrs 1-2x/d; PT bid 5d/wk qd; TEDs; Dietary replacements (?); hip protocol with 90 flexion.
FAMILY HISTORY: Mother and father, two brothers died of heart disease. Father was 86. Has three younger living sisters.
PSYCHOSOCIAL: Married at 18 yrs. for 48 years until husband’s death. No children. Worked as a secretary. Lived next door to her parents until neighborhood was razed for freeway construction; then lived in apartment.
ROS: Thoughts not clear during this interview. Responses to many questions were: “Well, you know everyone has to get up and go most days.” Was not able to answer direct questions; how often do you have to go to the BR during the night?
General: Feels good, denies pain and declined nurse’s offer for pain medication.
Skin: No dryness, itching, sores.
HEENT: No diplopia, blurring, tinnitus, dry mouth, difficulty swallowing or chewing, no HA or injuries.
Resp: Some tightness in R chest, coughs, needs to use “machine” (nebutezer) which helps her breath better. Doesn’t think she experiences SoB, dyspnea, PND, orthropnea.
Cardiovascular: No angina, tachycardia, palpitations.
Breast: No lumps, tenderness, thickening or discharge.
Abdomen: No indigestion, N-V-D-C, flats or difficulty passing stool. Last BM on this AM was hard. Drinks prune juice to keep regular.
GU: No urgency, burning or discomfort needs assist with toiling. No vaginal itching.
Peripheral/neurs: None
Endocrine: Low thyroid
Hematologic: No anemia, bleeding or clotting problem. Hx of transfusions thinks she must have had some at sometime.
Cog/Psych: “Fine”
PE:
Fairly neat elderly female sitting in WC alert with oriented engaging in reality-based conversation though responses are at times generalities with confusing thought pattern.
Skin: Warm dry intact – incision L hip 18” length, L knee 15” length
HEENT: Normocephalic, no TMJ click, conjugate gaze, hears normal voice tones. No glandular swellings or thyroid enlarge.
Resp: Even shallow resp with moist cough, crackles with BS R
Breast: No tender, no lump discharge.
Cardicavasc: Norm S1-S2, no carotid bruits or murmurs with pp Ap 88 Bp 120/90.
Abdominal: Soft nontender with BS no hepatosplenomegaly wt 158 Ht 5’4”
GU: Deferred.
Musculoskeletal: No crepetus, does not bear wt L leg, guarding with facial grimace with transfer WC to bed see cc.
Neuro: No Babinsky with little patellar reflex R, hand claps with coordinated movement.