Virtual follow up note

Date: 2026-01-11

Dear Dr. ,

RE: , 45, 

BACKGROUND:
• Open reduction and internal fixation of the left tibia performed four weeks ago.

CURRENT STATUS:
• Outpatient follow-up for left tibia injury post open reduction and internal fixation.
• Currently using a range of motion brace; patient reports difficulty with the brace.
• Incision is healing well. Swelling present, noted as a normal postoperative finding.
• Patient is completing Celebrex by Sunday and will transition to Advil and Tylenol for pain management.

ORTHOPEDICS PROGRESS:
• Patient instructed to continue range of motion exercises at home (flexing and extending the knee 50 times while seated).
• Compression socks recommended for swelling, to be worn first thing in the morning.
• Patient agreed to begin formal physical therapy.
• Non-weight bearing status maintained, allowing only touch-down weight bearing for balance.
• Brace to remain in use until follow-up x-rays confirm sufficient healing.

PLAN:
• Continue current regimen with range of motion brace and exercises.
• Begin formal physical therapy.
• Maintain non-weight bearing status.
• Transition to Advil and Tylenol after completing Celebrex.
• Follow-up with x-rays to assess healing and determine brace discontinuation.

Next appointment: To be scheduled for follow-up and x-ray assessment.

Sincerely,

Dr. Alex Chen