Plastic Surgery Follow-up - Adult

Subjective:
Chief Complaint:
Follow-up post right carpal tunnel release

History of Present Illness:
The patient presents for follow-up after right carpal tunnel release performed on May 13th. Since the procedure, the patient reports resolution of preoperative numbness and tingling. However, the patient continues to experience significant pain localized to the wrist, which is exacerbated by movement and use of the right hand. The patient notes particular difficulty with activities requiring grip strength, such as sewing or opening a car door, and has been compensating by using the left hand. The patient describes tenderness in the operative area and inquires about the presence of internal sutures. No new numbness or tingling has occurred since the surgery. The patient expresses concern regarding persistent discomfort and seeks advice on scar management and pain relief. The patient denies any other new symptoms.

Current Medications:
Patient is currently taking prescribed pain medications and antibiotics.

Objective:
Physical Examination:
General – Appears well, no obvious discomfort
ENT: [No cervical lymphadenopathy, throat normal with no erythema or exudates.]
Cardiovascular – [Heart rate regular, S1S2 normal with no murmurs or added sounds, peripheral pulses easily palpable, equal and symmetric, normal capillary refill, no JVD, no carotid bruits, no central or peripheral cyanosis, no clubbing, no peripheral edema.]
Respiratory – [Lungs clear to auscultation bilaterally with no wheezes or crackles, normal symmetrical chest expansion.]
Skin – [No rashes, no dry skin, no skin infections]
Abdomen – [Normal bowel sounds, abdomen soft and nontender, no distension.]
Musculoskeletal – [No tender, swollen, warm, or erythematous joints. Normal range of motion in examined limbs, no muscle tenderness.]
Neurological – [Alert and oriented in time, space and person, normal gait, strength 5/5 in upper and lower limbs, CN 2-12 grossly intact, coordination intact.]

Test Results:
[None required unless clinical situation warrants]

Vital Signs:
[Blood Pressure, Heart Rate, Respiratory Rate, Temperature]

Assessment:
Differential Diagnosis:
[List any differential diagnoses considered based on the current symptoms and findings.]

Impression:
Stable post-operative recovery with expected findings of minor bruising and edema.

Problem:
Minor bruising and residual edema

Plan:
Continue current post-operative care regimen, which includes wound care, medications, and activity restrictions. Monitor for signs of infection or complications. Prescribe additional medication for pain/swelling if necessary. Instruct patient to follow-up in [number] weeks for further evaluation.