Universal Dependencies - English - GENTLE

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Description:

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Followup 4 months status post percutaneous screw fixation of a right Schatzker IV tibial plateau fracture and second through fifth metatarsal head fractures treated nonoperatively.

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REASON FOR VISIT:

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Followup 4 months status post percutaneous screw fixation of a right Schatzker IV tibial plateau fracture and second through fifth metatarsal head fractures treated nonoperatively.

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HISTORY OF PRESENT ILLNESS:

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The patient is a 59-year-old gentleman who is now approximately 4 months status post percutaneous screw fixation of Schatzker IV tibial plateau fracture and nonoperative management of second through fifth metatarsal head fractures.

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He is currently at home and has left nursing home facility.

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He states that his pain is well controlled.

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He has been working with physical therapy two to three times a week.

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He has had no drainage or fever.

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He has noticed some increasing paresthesias in his bilateral feet but has a history of spinal stenosis with lower extremity neuropathy.

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FINDINGS:

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On physical exam, his incision is near well healed.

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He has no effusion noted.

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His range of motion is 10 to 105 degrees.

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He has no pain or crepitance.

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On examination of his right foot, he is nontender to palpation of the metatarsal heads.

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He has 4 out of 5 strength in EHL, FHL, tibialis, and gastroc-soleus complex.

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He does have decreased sensation to light touch in the L4-L5 distribution of his feet bilaterally.

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X-rays taken including AP and lateral of the right knee demonstrate a healed medial tibial plateau fracture status post percutaneous screw fixation.

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Examination of three views of the right foot demonstrates the second through fifth metatarsal head fractures.

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These appear to be extraarticular.

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They are all in a bayonet arrangement, but there appears to be bridging callus between the fragments on the oblique film.

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ASSESSMENT:

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Four months status post percutaneous screw fixation of the right medial tibial plateau and second through fifth metatarsal head fractures.

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PLANS:

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I would like the patient to continue working with physical therapy.

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He may be weight bearing as tolerated on his right side.

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I would like him to try to continue to work to gain full extension of the right knee and increase his knee flexion.

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I also would like him to work on ambulation and strengthening.

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I discussed with the patient his concerning symptoms of paresthesias.

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He said he has had the left thigh for a number of years and has been followed by a neurologist for this.

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He states that he has had some right-sided paresthesias now for a number of weeks.

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He claims he has no other symptoms of any worsening stenosis.

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I told him that I would see his neurologist for evaluation or possibly a spinal surgeon if his symptoms progress.

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The patient should follow up in 2 months at which time he should have AP and lateral of the right knee and three views of the right foot.