Ortho General Consult

Diagnosis:  Infect/inflm reaction due to int fix of left tibia, sequela (T84.623S)
Treatment Plan:  
- Approved for range of motion brace; adjustments to be made as needed for comfort
- Advised use of compression socks in the morning to help manage swelling
- Remain non-weight bearing; touch foot to ground for balance only
- Referral to formal physical therapy accepted
- Transition to Advil and Tylenol as needed after completing Celebrex
- Continue brace until follow-up x-rays confirm sufficient healing

Presentation:  45-year-old individual presenting for follow-up after open reduction and internal fixation of the left tibia performed four weeks ago. Reports incision is healing well but experiencing difficulty with the brace. Performing range of motion exercises at home.

Treatment to Date:  Open reduction and internal fixation of the left tibia performed four weeks ago. Patient has been using a brace and performing range of motion exercises at home. Currently completing a course of Celebrex.

Relevant Medical History: 

Allergies: 

Baseline Mobility & Function: 

Social History:  Pursuing a graduate degree and is from another country.

Physical Findings:  Incision on the left tibia is healing well. Swelling present, noted as a normal postoperative finding.

Procedures & Special Tests Undertaken: 

Available Imaging:  

Lab Tests: 

Other Relevant Information Not Captured Elsewhere:  

Impressions and Working Diagnosis:  Infect/inflm reaction due to int fix of left tibia, sequela (T84.623S)

Today, I had a discussion with this patient about my clinical impressions, including my provisional working diagnosis.   Also discussed today was natural history and various treatment options available for consideration. Attempts have been made to answer all questions.  

Treatment Options Reviewed  The patient was advised regarding continued use of the range of motion brace with adjustments for comfort, use of compression socks for swelling, non-weight bearing status, transition to over-the-counter pain medications after Celebrex, and referral to formal physical therapy. The need to continue the brace until follow-up x-rays confirm healing was also discussed.

After reviewing available treatment options, the following course of action has been recommended and agreed upon: 
Detailed Treatment Plan:  
- Continue range of motion brace with adjustments as needed
- Use compression socks in the morning
- Remain non-weight bearing, touch foot to ground for balance only
- Begin formal physical therapy
- Transition to Advil and Tylenol after Celebrex
- Continue brace until follow-up x-rays confirm healing

Follow-up Arrangements:  Follow-up visit to reassess healing and review x-rays.

Dr. Alex Chen