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PROBLEMS & DIAGNOSES
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CLINICAL NOTES
Result type:
Result date:
Result status:
Result title:
Performed by:
Verified by:
Encounter info:
Operative Report
September 30, 2011 7:14 AM CDT
Auth (Verified)
Operative Report
Ng, Dale J on November 03, 2011 6:25 PM CDT
Ng, Dale J on November 03, 2011 6:25 PM CDT
40000023425, KUMC, Inpatient, 9/30/2011 -
* Final Report *
DATE OF OPERATION: 09/30/2011
SURGEON: Dale Ng, MD
ASSISTANT(S):
Samantha Sterling, MD
Levi Fischer, RN
PREOPERATIVE DIAGNOSIS:
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Right knee pain, right knee genu varum, right knee degenerative arthritis.
POSTOPERATIVE DIAGNOSIS:
Same.
OPERATIVE PROCEDURE:
Right total knee arthroplasty.
ANESTHESIA:
General endotracheal.
Components Utilized: DePuy total knee system, size 5 posterior stabilized femoral component, size 4 tibial
component, size 17.5-mm thickness tibial articulated surface, size 38-mm round patella.
FINDINGS:
INDICATIONS FOR OPERATIVE PROCEDURE: Mr. Mickland is a pleasant 64-year-old gentleman with
multiple medical comorbidities and is about a year after his primary knee arthroplasty on the left. He has done
well with that. He presents from the right. He has severe varus deformity and no contracture, but again lot of
varus in addition to his tricompartmental degenerative disk disease. We discussed the risks, benefits,
alternatives, and complications involved with knee arthroplasty again. He voiced understanding and elected to
proceed.
DESCRIPTION OF OPERATIVE PROCEDURE: After being identified in the preoperative holding area, I
marked his right lower extremity. He was then brought back to the operating room. He was intubated by the
Anesthesia Service. He was positioned for surgery appropriately. All bony prominences were checked and
padded. The nonoperative extremity was covered with a foot squeezer and a TED hose to prevent DVT. All the
bony prominences checked and padded. His preoperative antibiotics have been administered previously. No
hair removal was required. I placed a nonsterile tourniquet. We then exsanguinated with an Esmarch. An
anterior skin incision was made and a median parapatellar arthrotomy was performed. He was noted to have
severe tricompartmental degenerative changes. I removed his meniscal tissue in addition to his infrapatellar fat
pad. The knee was again noted to have severe varus deformity. I was then able to perform a very large medial
release. I then cannulated the distal femur. I irrigated and suctioned the femoral canal and then placed the
distal femoral alignment guide. We then sized him to 5 after cutting him to 5-degree of valgus. I performed
anterior-posterior chamfer cuts. The distal femoral lug holes were placed as were the trial femoral component. I
then brought the knee through range of motion and noted that we felt severe varus deformity. I then placed
extramedullary tibial guide after removing the trial femoral component. Having done so, the knee was
osteotomized on the tibia. I resected 2 mm of bone off the most worn side, which was obviously the medial
side. He did have a significant amount of medial wear there. The wound was then irrigated. I performed a tibial
osteotomy. Having done so, the tibia was sized out as a 4. He had a significant amount of posterior
osteophyte. I debrided that away as well. Next, the knee was reduced with the aforementioned trial
components. I assessed the axial, coronal, and sagittal alignment as well as limb and component alignment on
the extremity. The native patella tracked nicely. I then removed 8 mm of bone with patellofemoral reaming
system. It was then sized out as a 38. I placed a 38 mm trial button. Having done so, the patellofemoral joint
tracked perfectly. The trial components were removed. I irrigated and suctioned the femoral canal copiously
and the bone ends as well. Antibiotic impregnated cement was utilized. I then cemented in his definitive
components after administering his first postoperative dose of antibiotic. Once the cement had been placed, I
then removed all residual cement debris and noted that the knee had no more residual cement. The trial
polyethylene tibial component was placed. I then reduced the knee, placed multiple lap sponges, held
compression. I let the tourniquet down. Total tourniquet was less than 50 minutes. The cement was allowed to
harden for 5 minutes. I achieved electrocautery hemostasis. The trial component was removed. I then
reinspected the knee. I found no residual cement debris or bone debris. The wound was irrigated 1 final time. I
then placed the definitive poly and then closed over a medium Hemovac drain with number 1 Vicryl for the
retinaculum, 0 and 2-0 Vicryl on the subcutaneous tissues, and then 3-0 nylon horizontal mattress sutures for
DISCLAIMER: All patient information appearing on this document is fictitious. Any resemblance to real persons, living or dead, is purely coincidental.
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skin. Sterile dressings were applied. He was transported to the recovery room on gurney without incident. On
arrival to the recovery room, he had a normal neurovascular exam.
Attestation: I attest I was present for and performed the entire procedure myself. There were no complications.
Dale Ng, MD
Result type:
Result date:
Result status:
Result title:
Performed by:
Verified by:
Encounter info:
Pharmacy Plan of Care
October 01, 2011 7:00 AM CDT
Auth (Verified)
Medication List
Brown, Benny on November 03, 2011 8:05 PM CDT
Brown, Benny on November 03, 2011 8:05 PM CDT
40000023425, KUMC, Inpatient, 9/30/2011 -
levofloxacin (LEVAQUIN) 250 mg/50 mL IVPB 250 mg Intravenous Q24H*
acetaminophen (TYLENOL) tablet 650 mg 650 mg Oral Q6H
amLODIPine (NORVASC) tablet 10 mg 10 mg Oral QHS
buPROPion SR (WELLBUTRIN-SR) tablet 150 mg 150 mg Oral QDAY
carvedilol (COREG) tablet 12.5 mg 12.5 mg Oral BID w/meals
doxazosin (CARDURA) tablet 8 mg 8 mg Oral QHS
finasteride (proSCAR) tablet 5 mg 5 mg Oral QDAY
lansoprazole DR (PREVACID) capsule 30 mg 30 mg Oral QDAY
loratadine (CLARITIN) tablet 10 mg 10 mg Oral QDAY
pregabalin (LYRICA) capsule 300 mg 300 mg Oral BID
tamsulosin (FLOMAX) capsule 0.4 mg 0.4 mg Oral QDAY after breakfast
docusate (COLACE) capsule 100 mg 100 mg Oral QDAY
levothyroxine (SYNTHROID) tablet 125 mcg 125 mcg Oral BID
losartan (COZAAR) tablet 100 mg 100 mg Oral QDAY
simvastatin (ZOCOR) tablet 20 mg 20 mg Oral QHS
milk of magnesia (CONC) oral suspension 10 mL 10 mL Oral QDAY(21)
enoxaparin (LOVENOX) syringe 40 mg 40 mg Subcutaneous QDAY(21)
insulin aspart (NOVOLOG) flexPEN 14 Units 14 Units Subcutaneous QID
Continuous Infusions:
ropivacaine (NAROPIN) 0.2% PCA PNC infusion (ON-Q) 550 mL (09/30/11 0725)
sodium chloride 0.9 % with KCl 20 mEq/L infusion 30 mL/hr (10/01/11 1000)
Result type:
Result date:
Result status:
Result title:
Performed by:
Verified by:
Progress Note-Physician
October 01, 2011 7:30 AM CDT
Auth (Verified)
Progress Note - Orthopedic Surgery
Ng, Dale J on November 03, 2011 6:26 PM CDT
Ng, Dale J on November 03, 2011 6:26 PM CDT
DISCLAIMER: All patient information appearing on this document is fictitious. Any resemblance to real persons, living or dead, is purely coincidental.
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Encounter info:
40000023425, KUMC, Inpatient, 9/30/2011 -
* Final Report *
S: No acute events. Patient tolerating current diet. Denies chest pain. Denies SOB.
O: Blood pressure 157/69, pulse 71, temperature 36.5 °C (97.7 °F), height 177.8 cm (70"), weight 121.8 kg
(268 lb) , SpO2 94.00%.
General: AAOx3, NAD
Cardiac: RR
Respirations: Unlabored
Abdomen: soft, nt
Extremities: RLE: DF,PF,EHL intact. SPN, DPN, t nerve intact.
Incisions: C/D/I
A/P: 64M R TKA
- PT/OT
- dvt prophylaxis
- WBAT RLE
- transition to oral pain meds
- renal dose levaquin per cardiology recs
- chronic renal insufficiency. Will continue to monitor
Result type:
Result date:
Result status:
Performed by:
Verified by:
Encounter info:
Progress Note-Physician
October 02, 2011 7:30 AM CDT
Auth (Verified)
Martinez, Lisa on November 03, 2011 8:09 PM CDT
Martinez, Lisa on November 03, 2011 8:09 PM CDT
40000023425, KUMC, Inpatient, 9/30/2011 -
* Final Report *
John E Mickland is a 64 y.o. male day 3 s/p right knee replacement by Orthopedics who was admitted to the ICU 10/1/11
for hypoxia and worsening respiratory failure.
Neuro/Psych:
History of Depression - stable
continue home wellbutrin: SR 150 mg q day
CV
Bradycardia - sinus
- monitor as patient is on Cored 12.5 mg BID
History of CHF
- s/p aggressive diuresis 10/1/11
DISCLAIMER: All patient information appearing on this document is fictitious. Any resemblance to real persons, living or dead, is purely coincidental.
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- EF 59% per stress test 9/9/11
CAD with PVD
- continue home meds, recent Cath 9/17/11 unchanged
HTN
- Continue home meds: amlodipine 10 mg q HS, Coreg 12.5mg BID, Cardura 8 mg q HS, Losartan 100 mg q day
HLD - stable
- continue home simvastatin 20 mg q HS
Respiratory:
Acute Respiratory Failure - DDX Pneumonia, fluid overload, PE (low suspicion with alternative explanation for
hypoxemia based upon infiltrates seen on chest xray)
- one episode of hemoptysis 10/1/11 AM, none since, scope revealed likely pulmonary in origin (pt with
recurrent epistaxis over last few days and epistaxis occurred while I was examining him. Suspect this maybe
source)
- Fluid Overload s/p aggressive diuresis, now euvolemic
- LE dopplers negative
- Fever, CXR 10/1/11 with possible infiltrates - likely Pneumonia
Hyperkalemia
- patient has been on NS + 20 meq KCl since admission
- will discontinue today
NPO at this time in case emergent need to intubate
Constipation 2/2 pain medications in post-operative period
- MOM 10 ml q day
- Colace q day
- Dulcolax PRN
Genitourinary/Renal:4
CKD, baseline creatinine 1.9-2.4
- patient with one kidney s/p left nephrectomy 2006 for renal cell carcinoma
- creatinine 2.49 today
Endocrine:
DM II – stable
- patient has been on Lantus 115 units q HS, Novolog 22/14/18 with meals
- due to NPO status will hold these medications, start SS insulin
- will resume home regimen when diet begins
DISCLAIMER: All patient information appearing on this document is fictitious. Any resemblance to real persons, living or dead, is purely coincidental.
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Hypothyroidism – stable
- on Levothyroxine 125 mcg BID
ID:
Sepsis – possible pneumonia
- febrile 101 on arrival to ICU
- started on Vanc/Zosyn/Levaquin
Musculoskeletal
Right knee replacement 9/30/11
- flexeril 10 mg TID PRN
- precocet 5/325 1-2 tabs q 4 hours prn
Derm
Skin lesions on nose suspicious for CA per ENT
- derm follow up as outpatient
Heme:
Anemia
- 11.2 Pre-operative  8.5 post-operative, appears stable
PPX
Lovenox 40 mg q day
Prevacid 30 mg q day
Disp:
- Full Code
- PCP: Lisa Martinez, MD,Lawrence, KS
Patient discussed with Dr. Dirks and Dr. Jackson
ATTESTATION
I have seen, personally fully evaluated, and discussed patient with resident Dr. Kuhn. I agree with the objective findings
and agree with the plan of care as documented by the resident with the exceptions noted. The patient is critically ill
with acute resp failure, pneumonia, sepsis, s/p knee replacement. I spent 40 minutes (excluding time spent performing
or supervising any procedures) providing and personally directing critical care services including radiology review,
antibiotic selection, 02 titration, and coordination of care.
64 y/o male with progressive hypoxemic resp failure and pulmonary infiltrates. Radiographically based upon the chest
xray, this looks suspicion for pulmonary edema. However, as this did not improve with aggressive diuresis yesterday and
patient spiked fever w/ leukocytosis (left shift) this AM, we suspect this is likely HCAP. HCAP Abx coverage initiated. With
significant hx of CAD, we will follow cardiac markers as pt is high risk for demand ischemia and related MI. With multiple
comorbidities the patient’s condition is guarded as risk for progression to septic shock remains a concern.
DISCLAIMER: All patient information appearing on this document is fictitious. Any resemblance to real persons, living or dead, is purely coincidental.
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Staff name: Martinez, MD Date: 10/02/2011
Result type:
Result date:
Result status:
Result title:
Performed by:
Verified by:
Encounter info:
Progress Note-Physician
October 02, 2011 3:00 PM CDT
Auth (Verified)
Post ICU Progress Note
Martinez, Lisa on November 22, 2011 11:06 AM CST
Martinez, Lisa on November 22, 2011 11:06 AM CST
40000023425, KUMC, Inpatient, 9/30/2011 -
* Final Report *
Patient was intubated on 09/30/11 due to worsening respiratory failure and pneumonia. Patient was extubated
10/2/2011.
Patient is to be moved from ICU to the orthopedic floor today. Infection has resolved; infiltrates are resolving on
radiography. Patient has been afebrile for 48 hours and is on a diabetic/renal diet and tolerating well.
Respiratory: No hemoptysis, NPC, resolving pneumonia; on 4 lpm NC with good oxygen saturation.
Continue all medications.
Attestation:
I have personally fully evaluated and discussed patient with Resident. I agree with the objective findings and agree with
the plan of care as documented by the resident with exceptions noted. The patient is recovering from pneumonia,
sepsis, and s/p knee replacement. I spent 40 minutes providing and personally directing medical care services including
radiology review, antibiotic selection, O2 titration, and coordination of care.
FORM BROWSER
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FLOWSHEET
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© KU Center for Health Informatics | Page 10 of 12
DISCLAIMER: All patient information appearing on this document is fictitious. Any resemblance to real persons, living or dead, is purely coincidental.
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ORDERS
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