A physical medicine and rehabilitation consult requested by the orthopedic service of Dr. ___ [NAME].
HISTORY OF PRESENT ILLNESS: This 65-year-old white male was admitted with the chief complaint of right knee pain. The patient had progressive severity over several years resistant to conservative care.
He was admitted ___ hospital on ___, underwent a right total knee arthroplasty by Dr. ___. Postop, he is currently taking fluids p.o., is afebrile. He has not yet been out of bed and is waiting therapy evaluations.
PAST MEDICAL HISTORY: Primary physician is Dr. ___ [NAME]. Past medical history is notable for hypertension; depression; osteoarthritis, both knees; early cataracts; glaucoma; corneal abrasion, left eye.
SURGERIES: Left hand, surgery transition of nerves. Patient also has known aortic stenosis. Has had an echocardiogram in the past.
ALLERGIES: NO KNOWN DRUG ALLERGIES.
SOCIAL HISTORY: Patient currently works as an administrator for an adult-care facility in ___. He currently is married but lives alone in a condominium in ___, and there are 2 levels with approximately 10 steps between levels.
FAMILY MEDICAL HISTORY: Mother deceased at age (86) with Alzheimers disease. Father deceased in ___. …show more content…
ENT: No problems swallowing or decreased hearing. Cardiac: No chest pain, arrhythmia. History of hypertension. Respiratory: No cough or pneumonia. GU: No urinary incontinence or frequency voiding. GI: No constipation or diarrhea. Musculoskeletal: Pain in both knees, right greater than left. Neurologic: No history of seizures or numbness. Endocrine: No diabetes. Psychiatric: Some depression, mild. Heme: No history of anemia. General: Patient notes 15-pound weight gain in the last 6 months. He feels it is secondary to inactivity. Mobility: Requiring