Patient Note (Carlyn)
Carlyn
(Patient ID 017)
| Name: Carlyn | Age: 76 | Admit date: 2 days ago | MR #: 000-017 |
| Gender Identity: Female | Race: Caucasian |
Admitting diagnosis: Total Hip Replacement |
Insurance: Medicare A |
| History of present illness: 76-year-old female with history of arthritis admitted 2 days ago for R posterolateral total hip replacement. She reports chronic pain of her hip. Rates the pain 10/10 in severity. She tried physical therapy without adequate relief and is seeking definitive surgical management. | |
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Past medical/surgical history: Osteoarthritis in B ankles, knees, and hips R ankle replacement 2 years ago R total knee replacement 3 years ago |
| Social History: Lives independently with supportive neighbors. Daughter lives 10 minutes away and visits 2-3x/week. Enjoys reading, cross stitch, and attending weekly book club at the senior center. | |
| Employment/work/school: Retired from textile factory. | |
| Prior level of function: Ambulated short distances within home. When in community walked short distances with front wheeled walker and frequent rest breaks. She utilized electric mobility vehicles while in stores. Has a walk-in shower with shower seat and adjustable shower head. Uses a bed side commode at night. Modified independent for toileting, bathing, dressing, cooking, and household tasks. Drove independently. | |
| Living situation/Environmental barriers: Lives in a two-story home with no steps to enter. Primary living spaces, bedroom, and bathroom are on the first floor. |
Hip precautions
OOB
Vitals q shift
Regular diet
Tylenol 650mg TID
Hydrocodone 10mg q6 PRN
R Hip xray: artificial right hip with hardware well aligned and intact
BP: 98/59
HR: 85
RR: 16
Temp: 98.6F
O2: 96% on room air
Disclaimer: Although the individuals in ICE videos are real patients, the exact history has been altered to protect their identities.