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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. |