Follow Up SOAP Note

Subjective:
I had a follow-up with the patient regarding the status of a left tibia injury, four weeks post open reduction and internal fixation. The patient reports that the incision is healing well, with no issues related to incision healing. The patient describes difficulty with the range of motion brace due to discomfort from squeezing. The patient notes ongoing swelling of the left lower extremity. The patient is performing range of motion exercises at home, specifically flexing and extending the knee fifty times while seated. The patient is currently completing a course of Celecoxib, which will be finished by Sunday.

Assessment:
The patient is in the postoperative period following open reduction and internal fixation of the left tibia. The incision is healing appropriately without complications. The patient is experiencing expected postoperative swelling and discomfort related to the brace. The patient is compliant with prescribed range of motion exercises and pain management regimen.

Follow-Up Plan:
I will follow up in accordance with radiographic reassessment to determine adequacy of bone healing and to guide progression of weight bearing. No weight bearing allowed, only touch foot to ground for balance.

Please do not hesitate to contact me with any concerns,

Regards,

Regional Medical Center