Post Operative: Six week follow-up

Transcription

1 Post Operatve Sx Week Follow-up - Knee Dated 9/5/ Post Operatve: Sx week follow-up Uncompartmental Knee Replacement (UKR) / Total Knee Replacement (TKR) Please complete ths booklet as soon as possble and return t n the enclosed envelope stamp requred.. OMB umber:. Date of Brth:. Date of Surgery:. Type (please tck relevant opton): Type of Operaton: UKR TKR UKR revsed to TKR TKR revson v Sde of Operaton: Rght Left Blateral.5 Date Sent:.6 Date Receved: Page Knee Specfc Assessment: Sx week follow-up nformaton - ICOAP 5 PanDETECT 6 Oxford Knee Score 7 Approved // OMB-CRF Verson. Page of 8

2 Post Operatve Sx Week Follow-up - Knee Dated 9/5/ Booklet completed on: Date: D D M M Snce leavng the hosptal, have you used any of the followng servces for problems related to your. knee and the operaton you had?. General Practtoner (GP): es. Hosptal Doctor: es. Physotherapst: es. urse/practtoner: es. of tmes seen n HS. of tmes seen n HS. of tmes seen n HS. of tmes seen n HS. of tmes seen prvately. of tmes seen prvately. of tmes seen prvately. of tmes seen prvately v v v v If yes, please state type of nurse/practtoner seen 5. Alternatve Practtoners (e.g. Chropractor, Osteopath, etc.): es. of tmes seen n HS. of tmes seen prvately v If yes, please state type of practtoner seen 6. Accdent and Emergency (A & E): es. of tmes seen If yes, please specfy 7. Home Care: Snce your operaton, have you receved any of the followng: Convalescence n a ursng Home? es If yes, for how long? hours / days / weeks Health care at Home? es If yes, for how long? hours / days / weeks Socal servce package of care? es If yes, for how long? hours / days / weeks Prvate package of care? es If yes, for how long? hours / days / weeks If yes, please specfy 8. Other HS Servces or Healthcare Professonals: es If yes, please state type of servce or professonal seen Approved // OMB-CRF Verson. Page of 8

3 Post Operatve Sx Week Follow-up - Knee Dated 9/5/. Have you had any of the followng problems snce you left the hosptal after your knee operaton? Please tck relevant opton and gve detals es. Have you receved any antbotcs for an nfecton n your knee snce you left the hosptal after your knee operaton? If yes, please gve detals:. Have you had a clot n your leg (known as DVT or Deep Ven Thromboss) snce you left the hosptal after your knee operaton? If yes, please gve detals:. Have you had a clot n your lungs (known as PE or Pulmonary Embolsm) snce you left the hosptal after your knee operaton? If yes, please gve detals:. Have you been seen or treated for any new heart or chest problems snce you left the hosptal after your knee operaton? If yes, please gve detals: 5. Have you experenced any problems wth movng your leg or foot on the operated sde snce you left the hosptal after your knee operaton? If yes, please gve detals: 6. Have you experenced any falls snce you left the hosptal after your knee operaton? If yes, how many? 7. Have you experenced any fractures snce you left the hosptal after your knee operaton? If yes, whch bone/s? Approved // OMB-CRF Verson. Page of 8

4 Post Operatve Sx Week Follow-up - Knee Dated 9/5/. Please tck relevant opton and gve detals f possble es. Have you been re-admtted to the uffeld Orthopaedc Centre because of problems wth your operated knee? If yes, please gve reason for admsson: Date of admsson: For how many days:. Have you been admtted to any other hosptal snce your dscharge from the uffeld Orthopaedc Centre, because of problems wth your operated knee? If yes, please gve reason for admsson: Date of admsson: For how many days: 5. Medcaton es. Have you changed any of your medcaton snce you left the hosptal after your knee operaton? If yes, please gve detals:. Have you bought any over-the-counter medcaton for problems related to your knee snce you left the hosptal after your knee operaton? If yes, please gve detals: Estmated cost of over-the-counter medcaton snce dscharge Approved // OMB-CRF Verson. Page of 8

5 Post Operatve Sx Week Follow-up - Knee Dated 9/5/ 6. ICOAP: Knee Verson People have told us that they experence dfferent knds of pan (ncludng achng or dscomfort) n ther knee. To get a better sense of the dfferent types of knee pan you may experence, we would lke to ask you about any constant pan (pan you have all the tme) separately from any pan that you may experence less often, that s, pan that comes. The followng questons wll ask you about the pan that you have experenced n your knee n the PAST WEEK. Please answer ALL questons. A. COSTAT PAI (for each of the followng questons, please select the response that best descrbes, on average, your constant knee pan n the PAST WEEK). In the past week, how ntense has your constant knee pan been? t at all / constant knee pan Mldly. In the past week, how much has your constant knee pan affected your sleep? t at all / constant knee pan Mldly. In the past week, how much has your constant knee pan affected your overall qualty of lfe? t at all / constant knee pan Mldly. In the past week, how frustrated or annoyed have you been by your constant knee pan? t at all / constant knee pan Mldly 5. In the past week, how upset or worred have you been by your constant knee pan? t at all / constant knee pan Mldly B. PAI THAT COMES AD GOES (for each of the followng questons, please select the response that best descrbes your knee pan that comes, on average, n the PAST WEEK) 6. In the past week, how ntense has your most severe knee pan that comes been? t at all / knee pan that comes Mldly 7. In the past week, how frequently has ths knee pan that comes occurred? ever / knee pan that comes and Rarely Sometmes Often Very often goes 8. In the past week, how much has your knee pan that comes affected your sleep? t at all / knee pan that comes Mldly 9. In the past week, how much has your knee pan that comes affected your overall qualty of lfe? t at all / knee pan that comes Mldly. In the past week, how frustrated or annoyed have you been by your knee pan that comes? t at all / knee pan that comes Mldly. In the past week, how upset or worred have you been by your knee pan that comes? t at all / knee pan that comes Mldly Verson : vember 9 7 Thank you! Approved // OMB-CRF Verson. Page 5 of 8

6 Post Operatve Sx Week Follow-up - Knee Dated 9/5/ 7. PanDETECT Approved // OMB-CRF Verson. Page 6 of 8

7 Post Operatve Sx Week Follow-up - Knee Dated 9/5/ 8. Oxford Knee Score. Durng the past weeks.. How would you descrbe the pan you usually have from your knee? ne Very mld Mld Moderate Severe. Durng the past weeks.. Have you had any trouble wth washng and dryng yourself (all over) because of your knee? trouble at all Very lttle trouble Moderate trouble Extreme dffculty Impossble to do. Durng the past weeks.. Have you had any trouble gettng n and out of a car or usng publc transport because of your knee (whchever you tend to use)? trouble at all Very lttle trouble Moderate trouble Extreme dffculty Impossble to do. Durng the past weeks.. For how long have you been able to walk before pan from you knee becomes severe (wth or wthout a stck)? pan / More than mnutes 6 to mnutes 5 to 5 mnutes Around the house only t at all pan severe on walkng 5. Durng the past weeks.. After a meal (sat at a table), how panful has t been for you to stand up from a char because of your knee? t at all panful Slghtly panful panful Very panful Unbearable 6. Durng the past weeks.. Have you been lmpng when walkng, because of your knee? Rarely / ever Sometmes or just at frst Often, not just at frst Most of the tme All of the tme 7. Durng the past weeks.. Could you kneel down and get up agan afterwards? es, easly Wth lttle dffculty Wth moderate dffculty Wth extreme dffculty, mpossble 8. Durng the past weeks.. Have you been troubled by pan from your knee n bed at nght? nghts Only or nghts Some nghts Most nghts Every nght 9. Durng the past weeks.. How much has pan from your knee nterfered wth your usual work (ncludng housework)? t at all A lttle bt Greatly Totally. Durng the past weeks.. Have you felt that your knee mght suddenly gve way or let you down? Rarely / ever Sometmes or just at frst Often, not just at frst Most of the tme All of the tme. Durng the past weeks.. Could you do the household shoppng on your own? es, easly Wth lttle dffculty Wth moderate dffculty Wth extreme dffculty, mpossble. Durng the past weeks.. Could you walk down one flght of stars? es, easly Wth lttle dffculty Wth moderate dffculty Wth extreme dffculty, mpossble Approved // OMB-CRF Verson. Page 7 of 8

8 Post Operatve Sx Week Follow-up - Knee Dated 9/5/ Thank you for completng and returnng the follow-up booklet n the stamped addressed envelope. Approved // OMB-CRF Verson. Page 8 of 8