Knee Injury Examination

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

Procedure: open reduction and internal fixation of left tibia
Procedure date: 4 weeks ago

History:
Left tibia injury sustained 4 weeks ago, requiring surgical intervention with open reduction and internal fixation. The patient has been non-weight bearing since the injury and is using a brace, though has reported some difficulty with it. Swelling is present but is noted to be a normal postoperative finding. The incision is healing well without signs of infection or complications. The patient has been performing range of motion exercises at home, flexing and extending the knee 50 times while sitting, without reported issues. No instability symptoms reported.

Past medical history: 
Medications: Celebrex (to be completed by Sunday), then Advil and Tylenol as needed
Allergies: No mention of allergies to Celebrex, Advil, or Tylenol
Activities: Pursuing a graduate degree

Physical Examination:
The incision is healing well. Swelling is present but expected postoperatively.

Impression and 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, with adjustments as needed for comfort. Compression socks were recommended to help manage swelling. The patient is to remain non-weight bearing, with foot touch to the ground for balance only. Referral for formal physical therapy will be arranged. Pain management to transition from Celebrex to Advil and Tylenol as needed after completing the current course. The brace will continue until follow-up x-rays confirm sufficient healing progress.

Follow-up: Planning to see in follow-up after repeat x-rays to assess healing and reconsider weight bearing.