Fracture/ Cast clinic notes

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Diagnosis: Oth fx upper end of l tibia, subs for clos fx w delay heal (S82.192G)
Prior Treatment: open reduction and internal fixation
Date of injury: Four weeks ago
Activities: pursuing a graduate degree

History: The patient is a 45-year-old who sustained a left tibia injury four weeks ago and subsequently underwent open reduction and internal fixation. The patient reports the incision is healing well but has had difficulty with the brace. They have been performing range of motion exercises at home, including flexing and extending the knee 50 times while sitting. The patient is currently completing a course of Celebrex, which will be finished by Sunday.

Physical Exam:
Incision is healing well. Swelling is present, which is a normal postoperative finding and expected to subside gradually.

Plan: The patient was instructed to continue using a range of motion brace, which will be adjusted as needed for comfort. Compression socks were recommended to manage swelling, with instructions to wear them first thing in the morning. The patient was advised to remain non-weight bearing, allowing only touch-down weight for balance. A referral for formal physical therapy was provided and accepted. For pain management, the patient was advised to transition to Advil and Tylenol as needed after completing Celebrex. The brace will remain in use until follow-up x-rays confirm adequate healing, which will be reassessed at the next scheduled appointment.