Whitlow discharge Feb 2023 hip

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1740 Hensley Fork Drive NW
Cleveland, TN 37311

Whitlow Memorial Hospital (423) 555-0138
whitlowmemorial.example

Discharge Summary
Patient: Lorraine M. Pruitt Date of birth: 02/11/1945 MRN: WM-0733916

Admitted: 02/02/2023 Discharged: 02/07/2023 Discharged to: Linden Court
Rehabilitation & Nursing

Attending: Garrett Voss, MD, Orthopedic Surgery Primary care: Samuel Tolbert, MD

Allergies: penicillin, sulfa drugs.

Diagnosis
Displaced fracture of the left femoral neck after a fall at home.

Procedure
Left hip hemiarthroplasty (cemented bipolar), 02/03/2023, G. Voss, MD. Spinal anesthesia.
Estimated blood loss 250 mL. No complications.

Hospital course
77-year-old woman with atrial fibrillation, type 2 diabetes and hypertension, found on her
kitchen floor after a fall during the night. Apixaban was held before surgery and restarted on
02/05/2023. Brief confusion on the first night after surgery, resolved by day 3. Walked 40 feet
with a walker and one assist on the day of discharge. Hemoglobin 9.4 at discharge.

Medications at discharge

Medication Dose How often

Apixaban (Eliquis) 5 mg twice daily

Metoprolol succinate ER 50 mg every morning

Losartan 50 mg every morning

Amlodipine 5 mg every morning

Metformin 1000 mg twice daily with meals

Glipizide 5 mg twice daily before meals

Levothyroxine 75 mcg every morning
Medication Dose How often

Atorvastatin 40 mg at bedtime

Gabapentin 300 mg at bedtime

Omeprazole 20 mg every morning

Alendronate 70 mg once a week

Latanoprost 0.005% 1 drop each eye at bedtime

Acetaminophen 650 mg every 6 hours

Tramadol (new) 50 mg every 6 hours as needed for pain, 14 days

Instructions
Weight bearing as tolerated with a walker. Posterior hip precautions for 6 weeks: do not
bend the hip past 90 degrees, do not cross the legs.
Staples out 14 days after surgery.
Follow up with Dr. Voss, Pine Knob Orthopaedics, on 02/21/2023.
Bone health should be reviewed by primary care after a fracture on alendronate.

Dictated by G. Voss, MD, 02/07/2023.

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Record

Whitlow discharge Feb 2023 hip Document · saved Feb 8, 2023

Values from records

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The record values this file is made from: the ones its text names with {{record.field}}, and the fields its template reads. A value here is in the file's source; whether it is readable depends on the look.

Value	Now
lorraine.date_of_birth	1945-02-11
hr-lorraine-2023-hip-surgery.date	2023-02-03

The values at render time were not recorded: the file was rendered before files/rendered.json existed. Rendering it again records them.

Planted

note_contradicts_record Levothyroxine, where the record is wrong. The prescription record still says 75 mcg; he never changed it. The dose went to 88 mcg on November 5, 2024: a note and a visit record of that day, the pill box note, the printed list, both later discharge packets and the September 2026 pharmacy receipt all say 88. The 2023 discharge summary says 75, which was right then. The right answer is 88 mcg, with the record called out as out of date.

note_contradicts_record Her allergies are in many places and not in the same words. Penicillin and sulfa are in all of them: the 2023 note, both discharge packets, the 2023 summary, the printed list, a note and a journal entry from May 2026. Codeine, oxycodone and lisinopril are intolerances in his note and on the hospital's sheets. The May 2026 face sheet also lists latex. His 2023 note says "no latex" and a note of May 22, 2026 says the hospital's entry is wrong and that he means to have it removed; nothing shows that it was. He is right, but an answer should give penicillin and sulfa as certain and report the latex entry as disputed.

attachments.yaml

record: doc-discharge-2023-hip
template: document
org:
  name: Whitlow Memorial Hospital
  lines:
  - 1740 Hensley Fork Drive NW
  - Cleveland, TN 37311
  phone: '4235550138'
  web: whitlowmemorial.example
  color: '#274b6d'
title: Discharge Summary
body: '**Patient:** Lorraine M. Pruitt &nbsp;&nbsp; **Date of birth:** {{lorraine.date_of_birth|mdy}}
  &nbsp;&nbsp; **MRN:** WM-0733916


  **Admitted:** 02/02/2023 &nbsp;&nbsp; **Discharged:** 02/07/2023 &nbsp;&nbsp; **Discharged to:** Linden
  Court Rehabilitation & Nursing


  **Attending:** Garrett Voss, MD, Orthopedic Surgery &nbsp;&nbsp; **Primary care:** Samuel Tolbert, MD


  **Allergies:** penicillin, sulfa drugs.


  ## Diagnosis


  Displaced fracture of the left femoral neck after a fall at home.


  ## Procedure


  Left hip hemiarthroplasty (cemented bipolar), {{hr-lorraine-2023-hip-surgery.date|mdy}}, G. Voss, MD.
  Spinal anesthesia. Estimated blood loss 250 mL. No complications.


  ## Hospital course


  77-year-old woman with atrial fibrillation, type 2 diabetes and hypertension, found on her kitchen floor
  after a fall during the night. Apixaban was held before surgery and restarted on 02/05/2023. Brief confusion
  on the first night after surgery, resolved by day 3. Walked 40 feet with a walker and one assist on
  the day of discharge. Hemoglobin 9.4 at discharge.


  ## Medications at discharge


  | Medication | Dose | How often |

  |---|---|---|

  | Apixaban (Eliquis) | 5 mg | twice daily |

  | Metoprolol succinate ER | 50 mg | every morning |

  | Losartan | 50 mg | every morning |

  | Amlodipine | 5 mg | every morning |

  | Metformin | 1000 mg | twice daily with meals |

  | Glipizide | 5 mg | twice daily before meals |

  | Levothyroxine | 75 mcg | every morning |

  | Atorvastatin | 40 mg | at bedtime |

  | Gabapentin | 300 mg | at bedtime |

  | Omeprazole | 20 mg | every morning |

  | Alendronate | 70 mg | once a week |

  | Latanoprost 0.005% | 1 drop each eye | at bedtime |

  | Acetaminophen | 650 mg | every 6 hours |

  | Tramadol (new) | 50 mg | every 6 hours as needed for pain, 14 days |


  ## Instructions


  - Weight bearing as tolerated with a walker. Posterior hip precautions for 6 weeks: do not bend the
  hip past 90 degrees, do not cross the legs.

  - Staples out 14 days after surgery.

  - Follow up with Dr. Voss, Pine Knob Orthopaedics, on 02/21/2023.

  - Bone health should be reviewed by primary care after a fracture on alendronate.


  Dictated by G. Voss, MD, 02/07/2023.

  '