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Notes

SUBJECTIVE:

Resting comfortable.  Pain relatively well managed.  Gradually improving.  

 

OBJECTIVE:

General Appearance: well-nourished, well developed in no acute distress

Orientation: oriented to person, place and time.    Mood / Affect: calm

Dressing clean, dry and intact 

Strength LE: 5/5 EHL, tibialis anterior, plantar flexion

Sensation: Subjective normal distal sensation bilaterally

Vasculature: <2 second capillary bilaterally    

Soft tissues: Normal .

 

 

ASSESSMENT:

 s/p Total Joint Replacement

 

PLAN:

Doing well and improving.  

PT, gait training.

Plan d/c home with outpatient PT.

Follow up in 2 weeks.  

   

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