Ortho - Follow Up / Post-Op Note

**Reason For Visit:** - Right foot bunionectomy follow-up (surgical follow-up). - Date 2024/11/01: 6 weeks post-operative. **Subjective:** - 52-year-old male, works as a software engineer, right-hand dominant. Recreational activities include walking and cycling. No associated injuries. - Patient states that he is experiencing mild pain in the right foot, rated as a 2/10 on the pain scale. Pain is worse with prolonged standing. No aggravating factors. Alleviating factors include rest and elevation. No associated symptoms. Prior bunionectomy performed 6 weeks ago. - Patient has returned to work, but duties are modified to allow for frequent breaks and elevation. - Occupational therapy has not been started. - Patient reports compliance with home exercise program, performing exercises twice daily. Exercises include ankle pumps and toe curls. **Physical Exam:** - Incision site is well-healed with no signs of infection. No erythema, induration, drainage, or breakdown. - Active ROM: Dorsiflexion to 10 degrees, plantarflexion to 30 degrees, inversion to 15 degrees, and eversion to 10 degrees. Passive ROM is within normal limits. - No joint instability or tenderness. - Nerve function intact. Strength 5/5 in all muscle groups. Sensation intact to light touch and pinprick. **Imaging/Other Studies Reviewed:** - X-rays of the right foot were reviewed and interpreted. Findings show good alignment and healing of the osteotomy. **Assessment & Plan:** 1. Right foot bunionectomy - Post-operative healing as expected. - Patient is progressing well, with good pain control and range of motion. - No referrals needed at this time. - Continue with weight-bearing as tolerated. Follow-up x-rays in 6 weeks. - Treatment options discussed included continued conservative management with activity modification and pain control. - Surgical details: Bunionectomy performed 6 weeks ago at [Clinic Name]. - Post-operative care plan: Continue with weight-bearing as tolerated. Continue with home exercise program. Follow-up in 6 weeks. - Complication monitoring instructions: Patient instructed to watch for signs of infection (increased pain, redness, swelling, drainage) and to contact the office immediately if these occur. "Additional Orthopaedic Issues or Conditions:" - None "Additional Notes:" - Patient was educated on proper shoe wear and the importance of continued activity modification. **Follow-up:** - Follow-up visit scheduled in 6 weeks at [Clinic Name]. - Purpose of follow-up visit: Wound check, ROM check, and x-ray review. - No special rooming or preparation instructions needed.