Hip Dysplasia Evaluation

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45-year-old individual seen in the Orthopedic clinic.

Reason for visit: Follow-up of left tibia injury after open reduction and internal fixation

The patient underwent an open reduction and internal fixation for a left tibia injury four weeks ago. The incision is reported to be healing well. The patient reports difficulty with the brace and has been performing range of motion exercises at home, including flexing and extending the knee 50 times while sitting. The patient mentioned completing a course of Celebrex this past Sunday. The patient is pursuing a graduate degree and is from another country.

EXAM TODAY
The incision on the left tibia is healing well. Swelling is present, which is noted to be a normal postoperative finding.

IMPRESSION AND TREATMENT PLAN
Infect/inflm reaction due to int fix of left tibia, subs (T84.623D)

The patient has been approved for a range of motion brace, and adjustments will be made as needed to ensure it does not cause discomfort. To help manage swelling, the patient was advised to consider using compression socks. The patient was instructed to remain non-weight bearing, with permission to touch the foot to the ground solely for balance purposes. A referral for formal physical therapy was offered and accepted, and arrangements will be made accordingly. For pain management, the patient was advised to transition to Advil and Tylenol as needed after completing the current course of Celebrex. The brace will continue to be worn until x-rays confirm sufficient healing, which will be reassessed during the next follow-up appointment.