Reference no: EM133594144

Question: Medical Record Analysis

This discharge summary contains 10 medical terms. Write each of them in a list and describe/explain them as you would to a nonmedical person. Use a term only one time.

Discharge Summary

Admitting Diagnosis: Osteoarthritis bilateral knees

Final Diagnosis: Osteoarthritis bilateral knees with right TKA

History of present illness: Patient is a 68 year old male. He reports he has experienced occasional knee pain and swelling since he injured his knees playing foot ball in high school. These symptoms became worse while he was in his 50s and working on a concrete surface. The right knee has always been more painful than the left. He saw his orthopedic surgeon six months ago because of the constant knee pain and swelling severe enough to interfere with sleep and all activities. He required a cane to walk. CT scan indicated severe bilateral osteoarthritis. He is admitted to the hospital at this time for TKR right knee.

Summary of Hospital Course: Patient tolerated the surgical procedure well. He began intensive physical therapy for lower extremity ROM and strengthening exercises and gait training with a walker. He received occupational therapy instruction in ADLs, especially dressing and personal care. He was able to transfer himself out of bed by the third post-op day and was able to ambulate 150 ft with a walker and dress himself on the fifth post-op day.

Discharge Plans: Patient was discharged home with his wife one week post-op. He will continue rehabilitation as an outpatient. Return to office for post-op checkup in one week.