Orthopedic New Patient Consult

History of present illness: 
The patient is a 45-year-old individual presenting for follow-up after open reduction and internal fixation of a left tibia injury. The patient reports that the surgical incision is healing well but has experienced some difficulty with the brace. They have been performing range of motion exercises at home, specifically flexing and extending the knee 50 times while sitting. The patient recently completed a course of Celebrex for pain management and is seeking guidance on ongoing care and rehabilitation. The patient’s goal is to optimize recovery and functional outcome following surgery.

Medical/Surgical History: 

Medications: 
- Celebrex (course to be completed this Sunday)
- Medication profile is available on the xxx Drug Information System

Social/Occupational History and Functional Inquiry: 
The patient is currently pursuing a graduate degree and is from another country.

Physical Examination:
The incision is reported to be healing well. Swelling is present, which is considered a normal postoperative finding and is expected to subside gradually.

Assessment & Plan:

1. Infect/inflm reaction due to int fix of left tibia, subs (T84.623D)
- Non-surgical treatment options: The patient was advised to continue using a range of motion brace, with adjustments as needed for comfort and to prevent excessive pressure. Compression socks were recommended to help manage swelling, with instructions to wear them first thing in the morning. The patient was instructed to remain non-weight bearing, allowing the foot to touch the ground only for balance. A referral for formal physical therapy was provided and accepted. For pain management, the patient was directed to transition to Advil and Tylenol as needed after completing Celebrex. The brace will remain in use until follow-up X-rays confirm sufficient healing progress.
- Relevant referrals: Referral to formal physical therapy provided and accepted.

Additional Notes: 
Patient education was provided regarding the normal course of postoperative swelling, the importance of range of motion exercises, brace use, compression socks, non-weight bearing precautions, and pain management strategies. Instructions were given for ongoing care, including activity restrictions and signs of complications to monitor. The patient’s concerns regarding brace discomfort and rehabilitation were addressed during the consultation.