DATE OF CONSULTATION: MM/DD/YYYY
REFERRING PHYSICIAN: John Doe, MD
REASON FOR CONSULTATION: Pain management.
CHIEF COMPLAINT: Left knee pain.
HISTORY OF PRESENT ILLNESS: The patient is a pleasant (XX)-year-old patient who underwent a left total knee replacement. Following the procedure, the patient was tried on various medications for management of pain and had problems. He apparently had a query of vasovagal episode, query of syncope following administration of parenteral narcotics. Within receiving one dose of Dilaudid, the patient started complaining of dry heaves and nausea. He also had problems with bradycardia and had to be resuscitated with atropine and ephedrine. He was subsequently transferred to the intensive care unit. We started him on oxycodone 10 to 20 mg p.o. q. 4 h. p.r.n. pain. He rates his pain this morning as being in the vicinity of about 2 to 3/10 even though he is on the CPM machine. The patient, however, has problems with dry heaves and also complains of dizziness. On talking to him, he states that he has a history of vertigo and had been on meclizine. However, he states that he does not use the medication on a regular basis.
His history is remarkable also for surgery, including four reconstructive surgeries performed approximately four years ago. However, he does not recall the pain medication that he was on. He was tried on codeine at one time and also had problems of nausea with that medication and hence did not continue with that. At the present time, however, he seems to be having reasonable control on oxycodone, but has some complaints of nausea. He has been referred to the pain service for postop pain management following his total knee replacement on the left side.
PAST MEDICAL HISTORY:
1. Osteoarthritis of the left knee.
2. Hyperlipidemia.
3. Hypertension.
PAST SURGICAL HISTORY:
1. Status post reconstructive arthroscopic surgery on right knee.
2. Status post appendectomy.
ALLERGIES: CODEINE, NAUSEA AND VOMITING.
CURRENT MEDICATIONS:
1. Ketorolac 15 mg IV q. 6 h.
2. Senokot 2 tablets p.o. at bedtime.
3. Lovenox 30 mg p.o. q. 12 h.
4. Morphine sulfate 1 mg IV q. 1-2 h. p.r.n. pain.
5. Ambien 10 mg p.o. at bedtime.
6. Hydroxyzine 25 mg IM q. 6 h.
7. Oxycodone 10 to 20 mg p.o. q. 3-4 h. p.r.n. pain.
FAMILY HISTORY: Positive for hypertension, diabetes, and osteoarthritis.
SOCIAL HISTORY: The patient quit smoking approximately 20 years ago. Alcohol: Nil. Drugs: Nil. Bowel and bladder habits essentially within normal limits.
REVIEW OF SYSTEMS: Based on a 14-point review of systems is positive for left knee pain, hypertension, osteoarthritis, and hyperlipidemia. Rest of the review of systems are negative following a detailed 14-point review of systems.
PHYSICAL EXAMINATION:
GENERAL: The patient is lying in bed, in no apparent pain at the present time.
VITAL SIGNS: Blood pressure 124/68, pulse 86 per minute, respirations 20, and saturation 98% on nasal prongs.
HEENT: Head, ears, eyes, nose and throat within normal limits.
LUNGS: Clear to auscultation.
HEART: S1 and S2 normal.
ABDOMEN: Soft, nontender, and nondistended. Bowel sounds are present.
CENTRAL NERVOUS SYSTEM: Alert and oriented x3. Cranial nerves II through XII intact.
EXTREMITIES: The patient is status post left knee surgery, undergoing therapy at the present time. Limited examination performed for fear of exacerbation of pain.
IMPRESSION: A (XX)-year-old patient status post left total knee replacement with pain management problems with very adverse reactions to parenteral narcotics.
PLAN: Plan of care for pain management is as follows:
1. Continue oxycodone 10 to 20 mg p.o. q. 3-4 h. p.r.n. pain.
2. We would recommend use of Phenergan suppository for management of nausea.
Thank you very much for the opportunity to see this patient. We shall follow on him.
