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quo, 4 lest. | human case for A 52-year-old male presenting for elective total right knee arthroplasty | Human Case Study Electronic Health Record (EHR) “yr Robert Jones 52 ylo Male Reason for encounter: Elective total right knee arthroplasty. IHKOaMan case 2025 Case Study Introduction This case study focuses on a 52-year-old male patient, Mr. John Matthews (pseudonym used for confidentiality), who presents for an elective total right knee arthroplasty. The patient has a longstanding history of right knee osteoarthritis, characterized by chronic pain, limited mobility, and progressive joint degeneration. After years of conservative management— including NSAIDs, physical therapy, and corticosteroid injections—the patient has elected to proceed with surgical intervention due to declining quality of life and functional limitations. Total knee arthroplasty (TKA), coded under CPT 27447, is a common orthopedic procedure intended to relieve pain and restore function in patients with severe knee joint damage. Elective TKA is typically considered in middle-aged to older adults when non-surgical treatments fail to provide sufficient symptom control. This case study will detail the patient’s history of present illness (HPI), past medical history, physical exam findings, expert diagnosis, and the multidisciplinary treatment plan, including preoperative preparation, intraoperative management, and postoperative care. Insurance: Private health insurance Primary Language: English Chief Complaint "I'm here for my scheduled right knee replacement surgery. The pain is getting worse, and I can't do my job properly anymore." History of Present IlIness (HPI) Mr. J.M. has experienced chronic right knee pain for approximately five years, progressively worsening over time. The pain is described as deep, aching, and located primarily in the medial and anterior regions of the knee. He rates the pain at 7/10 at rest and up to 9/10 with movement. Pain is aggravated by weight-bearing activities such as walking, stair climbing, and standing for long periods. The patient reports morning stiffness lasting 30—45 minutes, especially after waking or prolonged sitting. He has attempted several conservative treatments with limited success, including: - Nonsteroidal anti-inflammatory drugs (NSAIDs) (ibuprofen, naproxen) - Physical therapy for range of motion and strengthening - Intra-articular corticosteroid injections (last received 6 months ago) - Activity modification and weight management attempts His declining mobility has significantly affected both his occupational performance and daily living activities, prompting consideration for surgical intervention. Past Medical History (PMH) - Osteoarthritis (right knee) — Primary diagnosis - Hypertension — Controlled with medication (Lisinopril 10 mg daily) - Hyperlipidemia — On atorvastatin 20 mg daily - No history of diabetes, cardiac disease, or previous surgeries Past Surgical History - None Family Medical History - Father: Deceased, myocardial infarction at age 68 - Mother: Alive, history of osteoarthritis and hypertension - No known hereditary musculoskeletal disorders Social History - Tobacco use: None - Alcohol use: Occasional (1—2 drinks/week) - Right knee: Swelling, joint line tenderness, crepitus on movement - Decreased flexion and extension compared to the left knee - Gait: Antalgic gait noted; favors left leg - Vitals: BP 134/86, HR 76, RR 16, Temp 98.6°F This comprehensive background establishes a clear clinical context for evaluating the need for total knee arthroplasty and sets the stage for subsequent sections such as diagnosis, treatment plan, nursing interventions, and patient education. Here is the Expert Diagnosis and Treatment Plan for the case of a 52-year-old male undergoing elective total right knee arthroplasty (TKA). This section continues from the previously provided background and is designed to be clear, structured, and academically appropriate for nursing, medical, or allied health case assignments (e.g., Walden University). Expert Diagnosis and Treatment Plan Primary Diagnosis - Bilateral primary osteoarthritis of the right knee (ICD- 10: M17.11) This is a degenerative joint disease characterized by cartilage breakdown, bone-on-bone friction, and synovial inflammation, leading to pain, stiffness, and loss of function. Secondary Considerations - Obesity (BMI 30.4) — contributes to joint stress and postoperative risk - Hypertension — requires preoperative blood pressure control - Limited mobility and deconditioning — addressed through rehabilitation Treatment Plan 1. Preoperative Management Goals: Optimize patient’s medical condition, educate, and prevent complications. - Medical clearance: Conducted by primary care; labs, ECG, and chest X-ray normal. - Medication review: NSAIDs discontinued 3 days prior to reduce bleeding risk. - Anesthesia evaluation: Approved for spinal anesthesia with sedation. - Patient education: o Explanation of the surgical procedure, risks, benefits, and recovery expectations. Initiate thromboprophylaxis: Low-molecular-weight heparin or aspirin + SCDs Encourage early mobilization with PT (post-op day 1). Begin isometric quadriceps and ankle pump exercises. B. Short-Term Goals (Day 2 to Week 2) Continue physical therapy: Range of motion (ROM), weight-bearing as tolerated. Pain control with oral medications (e.g., acetaminophen + PRN oxycodone). Wound care and monitoring for infection, DVT, bleeding. Assess for constipation due to opioids — stool softeners prescribed. C. Long-Term Goals (2-12 weeks) Gradual improvement in knee ROM (goal: 0-120 degrees). Strengthening exercises and gait training with walker — cane — independent. Return to normal ADLs within 6—12 weeks. Continue DVT prophylaxis until full ambulation is achieved. Follow-Up Appointments - 1-week postop: wound check and dressing change - 2-week postop: suture/staple removal (if present) - 6-week and 12-week follow-up: ROM evaluation, mobility assessment Patient Education Summary Signs of infection, DVT, or complications to report immediately. Use of walker or crutches as instructed by PT. Importance of adherence to PT for long-term surgical success. Nutrition and hydration to support healing. Expected Outcomes Pain reduction and improved joint function within 6—12 weeks Restoration of independent mobility Prevention of surgical complications Enhanced quality of life and return to work (light duty initially) Here is a comprehensive section on the Implementation of the case study for a 52-year-old male undergoing elective Total Right Knee Arthroplasty (TKA). This section describes the nursing interventions, multidisciplinary coordination, patient education, and rehabilitation efforts carried out to support optimal recovery. It aligns with nursing standards and academic expectations (e.g., Walden University case study format). Role: Surgical Nurse/OR Team - Assisted in preparing the sterile field and ensured proper positioning of the patient. - Maintained surgical time-out protocol to verify correct site and procedure. - Administered IV antibiotics pre-incision as ordered. - Applied sequential compression devices (SCDs) intraoperatively. t= 3. Immediate Postoperative Nursing Interventions (PACU & Surgical Unit) a. Pain & Comfort Management - Administered IV acetaminophen and monitored response. - Transitioned to oral analgesics (oxycodone PRN) when tolerated. - Encouraged use of pain scale and non-pharmacologic comfort methods (positioning, ice pack). b. Vital Signs & Neurovascular Checks - Monitored vital signs every 15 minutes x 1 hour, then per protocol. - Assessed surgical site dressing for bleeding or drainage. - Performed neurovascular checks (pulses, cap refill, sensation, movement) of the right leg. c. DVT Prevention Continued SCDs and initiated LMWH or aspirin for anticoagulation. Taught and encouraged ankle pumps and early mobilization. d. Mobility Collaborated with physical therapy for bed mobility and first ambulation on postoperative day 1. Reinforced safe use of walker and proper weight-bearing technique. oe) Ei 4. Multidisciplinary Collaboration Orthopedic Surgeon: Provided surgical care and directed clinical decisions. Physical Therapist: Led rehabilitation for range of motion, gait training, and strengthening. Case Manager: Coordinated discharge planning, home care, and DME (walker, raised toilet seat). Pharmacist: Reviewed medications, ensured proper pain regimen, and confirmed DVT prophylaxis plan. & 5. Patient & Family Education a. Postoperative Care at Home Provided written and verbal instructions on wound care and signs of infection (redness, warmth, discharge). Goal Outcome Maintain clear surgical . . . 8 No signs of infection observed site Patient verbalizes Patient and wife able to demonstrate understanding ofhome knowledge of wound care and DVT care signs Adheres to physical Verified by outpatient PT therapy plan coordination Great! Here's the Evaluation and Conclusion section of the case study for the 52-year-old male undergoing elective total right knee arthroplasty. This completes the formal case study write-up following academic and clinical standards (e.g., Walden University nursing case study format). Evaluation Evaluation focuses on whether the patient outcomes aligned with the goals set during the care plan and implementation. Below is an assessment of both short- and long-term goals: Goal Outcome Evaluation Effective pain control Pain reported as 3/10 with Goal Met (pain < 4/10 by POD 2) oral meds Goal Outcome Evaluation Ambulate with assistive Ambulated with walker on device by POD 1 morning of POD 1 Se Maintain intact surgical Surgical site clean, dry, Goal Met site without infection and approximated Prevent DVT through No signs of swelling, Goal Met prophylaxis tenderness, or calf pain ont Ugacerrare sean vopet wound understanding of Proper Goal Met . . . care and medication discharge instructions : regimen 7 . Referral confirmed, Transition to outpatient patient attended first Goal Met Lett otto Nad) outpatient session Conclusion This case study presents the successful perioperative management of a 52-year-old male patient undergoing elective total right knee arthroplasty due to end-stage osteoarthritis. The collaborative and evidence-based care provided by the multidisciplinary team—including nursing, surgery, anesthesia, physical therapy, pharmacy, and case management—resulted in a positive surgical outcome, effective pain management, and rapid mobilization. Nursing interventions played a central role in achieving the goals of early ambulation, complication prevention, and patient education. The use of structured preoperative teaching, vigilant postoperative monitoring, pain control strategies, and early tasks. Failed conservative treatments (NSAIDs, PT, steroid injections). - PMH: o Hypertension o Hyperlipidemia o Osteoarthritis (right knee) - PSH: None - Medications: o Lisinopril 10 mg daily o Atorvastatin 20 mg daily o Ibuprofen PRN (discontinued 3 days pre-op) - Allergies: NKDA - Social History: Non-smoker, occasional alcohol, lives with wife, employed as a warehouse supervisor - Review of Systems: o MSK: Knee pain and stiffness o No chest pain, SOB, or neurological symptoms O — Objective - Vital Signs: BP 134/86, HR 76, RR 16, Temp 98.6°F, BMI 30.4 - Physical Exam: o Right knee: Swollen, tender, limited ROM, crepitus o Antalgic gait, decreased weight-bearing - Diagnostics: o X-ray: Severe joint space narrowing, osteophyte formation, bone-on-bone contact o Labs, ECG, and chest X-ray pre-op: WNL A — Assessment Primary Diagnosis: - M17.11 — Unilateral primary osteoarthritis, right knee Secondary Considerations: - Class I obesity (BMI 30.4) - Well-controlled hypertension and hyperlipidemia P — Plan Preoperative: - Medical clearance completed - NSAIDs held 3 days prior - Pre-op teaching: procedure, pain control, DVT prevention, exercises - IV antibiotic within 1 hour pre-incision Surgical: - Procedure: Elective Total Right Knee Arthroplasty (CPT 27447) - Anesthesia: Spinal with sedation - Cemented prosthesis, SCDs applied intraoperatively Postoperative: - Pain management: IV to oral analgesics 
