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% ── Title ────────────────────────────────────────────────────────────────────
\title{\vspace{-1.5cm}\textbf{Post-Operative Treatment Plan}\\[2pt]
\large Total Knee Arthroplasty --- De-Identified Adult Case}
\author{Multidisciplinary Orthopedic Care Team}
\date{April 11, 2026}

\begin{document}
\maketitle
\thispagestyle{empty}
\hipaanotice
\vspace{-0.5cm}

\begin{patientinfo}
\small
\begin{tabular}{@{}ll@{\hspace{0.8cm}}ll@{}}
\textbf{Case ID:}   & TKA-2025-0042          & \textbf{Age/Sex:}      & 67 y/o Female \\
\textbf{BMI:}        & 29.4                   & \textbf{Allergies:}    & Sulfa (rash) \\
\textbf{Dx:}         & Primary OA, R knee \icdcode{M17.11} & \textbf{Severity:} & KL Grade IV \\
\textbf{Procedure:}  & R TKA (27447), med. parapatellar & \textbf{Implant:} & Cemented PS \\
\textbf{Anesthesia:} & Spinal + femoral block & \textbf{EBL:}          & 250 mL; no complications \\
\end{tabular}

\textbf{Comorbidities:} HTN (Lisinopril 10 mg), T2DM (Metformin 1 g BID), Osteoporosis (Alendronate 70 mg/wk + Ca/Vit D).
\end{patientinfo}

\vspace{0.05cm}

\begin{goalbox}[Treatment Goals (SMART)]
\begin{itemize}[nosep,leftmargin=*]
  \item \textbf{Pain:} NRS $\leq$4/10 at rest by POD 3; $\leq$2/10 at 6 wks \evidencelevel{AAOS CPG 2023}
  \item \textbf{ROM:} 0\textdegree/90\textdegree{} by 2 wks; 0\textdegree/115\textdegree{} by 6 wks; 0\textdegree/125\textdegree{} by 12 wks
  \item \textbf{Mobility:} Walker transfers POD 1; 150 ft ambulation by discharge; cane 6 wks; device-free 12 wks
  \item \textbf{Function:} KOOS Pain $\geq$75 by 3 months; return to community activities
\end{itemize}
\end{goalbox}

\vspace{0.05cm}

\begin{keybox}[Core Interventions]
\begin{itemize}[nosep,leftmargin=*]
  \item \textbf{Multimodal analgesia:} Scheduled acetaminophen + celecoxib; oxycodone PRN taper $\leq$2 wks; cryo
  \item \textbf{VTE prophylaxis:} ASA 81 mg BID $\times$ 4 wks + SCDs + early mobilization
  \item \textbf{Rehabilitation:} PT starting POD 0; phased progression over 12 wks (see Sec.~3)
  \item \textbf{Glycemic control:} BG QID inpatient; target 140--180 mg/dL; resume metformin with meals
\end{itemize}
\end{keybox}

\vspace{0.05cm}

\begin{warningbox}[Critical Decision Points]
\begin{itemize}[nosep,leftmargin=*]
  \item \textbf{VTE red flags:} Calf swelling, chest pain, tachypnea $\rightarrow$ urgent duplex/CTA
  \item \textbf{Wound:} Erythema $>$2 cm, purulent drainage, temp $>$101.5\textdegree F $\rightarrow$ ortho contact $<$24 h
  \item \textbf{Sulfa allergy:} Avoid sulfonamide antibiotics; celecoxib safe (no cross-reactivity)
  \item \textbf{Fall risk:} Osteoporosis + post-op instability; enforce walker/cane use; home safety eval
\end{itemize}
\end{warningbox}

\newpage

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%  PAGE 2 — MEDICATION PLAN & MONITORING
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\section{Discharge Medication Plan}

\small
\begin{center}
\begin{tabular}{@{}p{2.6cm}p{1.6cm}p{2.5cm}p{2.2cm}p{3.2cm}@{}}
\toprule
\textbf{Medication} & \textbf{Dose} & \textbf{Frequency} & \textbf{Duration} & \textbf{Notes} \\
\midrule
Acetaminophen & 1000 mg & Q6H scheduled & 4 weeks & Max 3 g/day \\
Celecoxib & 200 mg & BID & 2 weeks & With PPI below \\
Pantoprazole & 40 mg & Daily & While on NSAID & GI prophylaxis \\
Oxycodone & 5 mg & Q4-6H PRN & Taper $\leq$2 wks & Wean 25\%/3 days \\
Aspirin & 81 mg & BID & 4 weeks & VTE prophylaxis \\
\bottomrule
\end{tabular}
\end{center}
\normalsize
\textit{Continue home meds:} Lisinopril 10 mg daily, Metformin 1000 mg BID, Alendronate 70 mg weekly, Ca/Vit D.\smallskip

\section{Monitoring Parameters}

\begin{infobox}[Inpatient Monitoring (POD 0--2)]
\begin{itemize}[nosep,leftmargin=*]
  \item \textbf{Vitals:} Q4H (HR, BP, SpO$_2$, Temp, RR) --- flag MAP $<$65 or temp $>$101.5\textdegree F
  \item \textbf{Pain:} NRS at rest and with activity Q4H; goal $\leq$4/10
  \item \textbf{Neurovascular:} Distal pulse, sensation, motor Q4H $\times$ 24 h, then Q shift
  \item \textbf{Wound:} Dressing integrity, drainage character/volume; reinforce only, first change POD 2
  \item \textbf{Labs:} CBC and BMP POD 1; BG QID; transfuse if Hgb $<$7 g/dL (or $<$8 if symptomatic)
  \item \textbf{VTE:} SCDs while in bed; early ambulation POD 0; Homans sign assessment daily
  \item \textbf{I\&O:} Strict until foley removed (goal POD 1); monitor for urinary retention post-spinal
\end{itemize}
\end{infobox}

\begin{infobox}[Outpatient Monitoring Schedule]
\begin{itemize}[nosep,leftmargin=*]
  \item \textbf{2-week visit:} Wound check, staple/suture removal, ROM assessment, pain review, medication reconciliation
  \item \textbf{6-week visit:} AP/lateral radiographs, ROM goniometry, gait assessment, advance activity level
  \item \textbf{3-month visit:} KOOS score, functional assessment, discharge from PT if goals met
  \item \textbf{6-month \& 1-year:} Radiographs, implant surveillance, long-term function assessment
\end{itemize}
\end{infobox}

\section{Phased Rehabilitation Protocol}

\subsection{Phase I --- Acute Inpatient (POD 0--3)}
\begin{itemize}[nosep,leftmargin=*]
  \item PT 2$\times$/day: Ankle pumps, quad sets, SLR, edge-of-bed knee flexion
  \item Weight-bearing as tolerated with walker; ambulate 50--150 ft by discharge
  \item CPM or active-assisted ROM 0--90\textdegree{} as tolerated
  \item Cryotherapy 20 min Q2H while awake; elevation when resting
  \item \textbf{Discharge criteria:} Pain controlled on oral meds, ROM $\geq$80\textdegree, safe transfers, voiding independently, wound stable
\end{itemize}

\subsection{Phase II --- Early Recovery (Weeks 1--6)}
\begin{itemize}[nosep,leftmargin=*]
  \item Outpatient PT 3$\times$/week: progressive ROM, closed-chain strengthening, gait training
  \item \textbf{Week 1--2:} WBAT with walker, ROM target 0\textdegree{}/90\textdegree{}, quad/hamstring isometrics, heel slides
  \item \textbf{Week 3--4:} Transition to cane, ROM target 0\textdegree{}/110\textdegree{}, mini-squats, step-ups
  \item \textbf{Week 5--6:} Stair negotiation step-over-step, stationary bike, single-leg balance
  \item Home exercise program: 2$\times$/day (ROM + strengthening); daily walking program 10--20 min
  \item Opioid taper complete by week 2; transition to acetaminophen/NSAID only
\end{itemize}

\subsection{Phase III --- Strengthening (Weeks 7--12)}
\begin{itemize}[nosep,leftmargin=*]
  \item PT 2$\times$/week: functional training emphasis
  \item ROM target: full extension to $\geq$125\textdegree{} flexion
  \item Progressive resistance: leg press, wall squats, resisted terminal knee extension
  \item Balance and proprioception: single-leg stance, perturbation training
  \item Low-impact cardio: stationary bike 20--30 min, aquatic therapy if available
  \item Community reintegration: outdoor walking, light gardening
\end{itemize}

\subsection{Phase IV --- Return to Activity (Months 4--6+)}
\begin{itemize}[nosep,leftmargin=*]
  \item Independent home program; PT discharge when goals met
  \item Full activity without device; permitted: walking, cycling, swimming, golf, gardening
  \item Avoid high-impact sports, deep squatting/kneeling on hard surfaces; annual follow-up with radiographs
\end{itemize}

\section{Patient Education \& Safety}

\begin{warningbox}[When to Seek Immediate Care]
\begin{itemize}[nosep,leftmargin=*]
  \item Fever $>$101.5\textdegree F, increasing redness/warmth/drainage at incision
  \item New calf pain, swelling, or redness (possible DVT)
  \item Sudden chest pain, shortness of breath (possible PE --- call 911)
  \item Inability to bear weight or feeling of knee ``giving way''
\end{itemize}
\end{warningbox}

\begin{infobox}[Key Patient Instructions]
\begin{itemize}[nosep,leftmargin=*]
  \item Ice and elevate 20 min every 2 hours while awake for first 2 weeks
  \item No driving until off opioids, ROM adequate for pedal control, and cleared by surgeon ($\sim$4--6 wks)
  \item Shower OK 48 h after dressing removal; no submersion (bath/pool) until wound fully healed ($\sim$3--4 wks)
  \item Dental prophylaxis antibiotics for 2 years post-TKA per ADA/AAOS joint statement
\end{itemize}
\end{infobox}

\section{HIPAA Compliance \& Signatures}

\small De-identified per HIPAA Safe Harbor (45 CFR \S164.514(b)(2)). All 18 PHI identifiers removed. Case ID is randomly assigned with no link to medical records. For clinical demonstration only --- not an active medical order.\normalsize

\vspace{0.3cm}

\begin{tabular}{@{}p{7cm}p{6cm}@{}}
\rule{6cm}{0.4pt} & \rule{5cm}{0.4pt} \\
\textbf{Attending Orthopedic Surgeon} & \textbf{Date} \\[0.5cm]
\rule{6cm}{0.4pt} & \rule{5cm}{0.4pt} \\
\textbf{Physical Therapy Lead} & \textbf{Date} \\[0.5cm]
\rule{6cm}{0.4pt} & \rule{5cm}{0.4pt} \\
\textbf{Patient / Authorized Representative} & \textbf{Date} \\
\end{tabular}

\end{document}
