Sample Type / Medical Specialty: SOAP / Chart / Progress Notes
Sample Name: ORIF - Followup
Followup visit status post removal of external fixator and status post open reduction internal fixation of right tibial plateau fracture.
(Medical Transcription Sample Report)
REASON FOR VISIT:
Followup visit status post removal of external fixator and status post open reduction internal fixation of right tibial plateau fracture.HISTORY OF PRESENT ILLNESS:
The patient is now approximately week status post removal of Ex-Fix from the right knee with an MUA following open reduction internal fixation of right tibial plateau fracture. The patient states that this pain is well controlled. He has had no fevers, chills or night sweats. He has had some mild drainage from his pin sites. He just started doing range of motion type exercises for his right knee. He has had no numbness or tingling.FINDINGS:
On exam, his pin sites had no erythema. There is some mild drainage but they have been dressing with bacitracin, it looks like there may be part of the fluid noted. The patient had 3/5 strength in the EHL, FHL. He has intact sensation to light touch in a DP, SP, and tibial nerve distribution.
X-rays taken include three views of the right knee. It demonstrate status post open reduction internal fixation of the right tibial plateau with excellent hardware placement and alignment.ASSESSMENT:
Status post open reduction and internal fixation of right tibial plateau fracture with removal ex fix.PLANS:
I gave the patient a prescription for aggressive range of motion of the right knee. I would like to really work on this as he has not had much up to this time. He should remain nonweightbearing. I would like to have him return in 2 weeks' time to assess his knee range of motion. He should not need x-rays at that time.
soap / chart / progress notes, external fixator, open reduction internal fixation, tibial plateau fracture., ex fix, tibial plateau fracture, internal fixation, tibial plateau, orif,
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