CHIEF COMPLAINT: Right leg pain.
SUBJECTIVE: Nicholas is a (XX)-year-old, right-hand dominant, previously community ambulatory Hispanic male with a past medical history significant for osteochondroma of right distal femur and nicotine dependence who presents for a second opinion regarding right leg pain. In June XXXX, he sustained an open right distal tibia/fibular fracture and underwent debridement, irrigation and intramedullary nailing performed at an outside facility. He had no problems with wound healing problem or infection in the postoperative period. He went to have his proximal and distal locking screws removed in November. His fracture has gone on to heal; however, he continues to have lower leg pain centered at the fracture site. He had seen Dr. John Doe recently, and he presents upon referral for another opinion. Again, he denies any history of infection after his surgery. He denies any other orthopedic symptoms. He does have a patch of decreased sensation over the lateral aspect of the forefoot and at the fracture site. He is a laborer, and he is on his feet all day. He is starting a new job next week. He denies any fevers, chills or night sweats or any other constitutional symptoms.
PAST MEDICAL HISTORY: As above.
PAST SURGICAL HISTORY: As above in addition to excision of osteochondroma, right femur, hydrocele repair, and right wrist surgery.
ALLERGIES: None.
MEDICATIONS: None.
SOCIAL HISTORY: The patient smokes approximately half a pack of cigarettes on a daily basis. He denies alcohol or illicit drugs.
FAMILY HISTORY: Noncontributory.
REVIEW OF SYSTEMS: Significant for right leg pain.
OBJECTIVE: On examination of the right lower extremity, the surgical and traumatic wounds are completely healed. There are no local signs of infection. There is no soft tissue swelling, ecchymosis or edema. The foot is warm and well perfused with brisk capillary refill. Dorsalis pedis pulse is palpable and strong. Sensation is grossly intact to light touch distally in the distribution of the sural, saphenous, superficial, peroneal, deep peroneal and tibial nerves. There is decreased sensation, however, over the dorsolateral aspect of the foot. There is no tenderness to palpation over the knee or ankle. There is no tenderness to palpation at the tibia. There is no tenderness to palpation at fracture site. Active range of motion of the knee is from full extension to 155 degrees of knee flexion. Arc motion is pain-free. The knee is stable to varus-valgus stress testing at 0 and 30 degrees of flexion. There is no tenderness to palpation about the malleoli. Range of motion of the ankle is from 10 degrees of dorsiflexion to 45 degrees of plantarflexion. Arc motion is pain-free. There is no calf pain, swelling or tenderness to palpation. His gait is examined. It is nonantalgic in nature. He has no pain with weightbearing at the present time.
Radiographs of the right tibia demonstrate a well-aligned, healed distal third tibia fracture with associated fibular fracture. Proximal and distal interlocking screws have been removed.
ASSESSMENT AND PLAN: History of debridement and irrigation of open right distal tibia fracture treated with trimming, irrigation and intramedullary nailing. The diagnosis was reviewed in detail with his mother. Given history of open fracture, there is certainly concern about chronic occult infection; however, recent C-reactive protein is completely normal and, clinically, he does not have any signs of infection. His fracture has gone onto clinical and radiographic union and is well aligned. He does have some muscle weakness, specifically, quadriceps, hamstrings and gastrocnemius muscle complex. We do feel outpatient physical therapy is indicated to work on range of motion exercises as well as conditioning and strength training. This may improve some of his symptoms. I do not feel that hardware removal is indicated at the present time. He does have some issues with chronic pain, and we do feel that evaluation by a pain management specialist is indicated. We have made a referral to Dr. Jane Doe. We have given him a prescription for physical therapy, and we will see him back in approximately 8-10 weeks for repeat clinical and x-ray examination with AP and lateral x-rays of the right tibia. He understands the treatment plan above.
