Post Operative Follow-Up Note

Clinician Specialty: Orthopaedic Surgeon **Post Operative Follow-Up Note** **Procedure Performed:** Right Total Hip Arthroplasty (THA) **Date of Surgery:** 1 November 2024 **Progress:** Patient reports good overall progress since surgery. Pain levels are consistently managed with paracetamol, rating 2/10 at rest and 4/10 with activity. Mobility has improved significantly; patient is now able to ambulate with a single crutch for short distances indoors. No reported falls or significant complications. **Physiotherapy if appropriate** Attending regular physiotherapy sessions three times a week. Currently focusing on hip abduction and extension exercises, as well as gait training. Has achieved 90 degrees of hip flexion and full extension. Physiotherapist notes good patient compliance and steady progress towards independence. **Surgical Site Examination:** Surgical incision on the right hip is clean, dry, and well-approximated. No signs of erythema, induration, or purulent drainage. Staples were removed successfully at the 2-week post-op visit. A small amount of serous discharge noted on dressing change two days ago, now resolved. Scar is healing well. **Physical Examination:** Vital signs stable: BP 128/78 mmHg, HR 72 bpm, RR 16 bpm, Temp 36.7°C. Right hip active range of motion: Flexion 95°, Extension 0°, Abduction 30°, Adduction 10°, Internal Rotation 15°, External Rotation 20°. No significant oedema in the affected limb. Peripheral pulses 2+ bilaterally. Muscle strength 4/5 in hip flexors and extensors. Negative DVT signs. **Imaging:** Recent X-ray (dated 28 October 2024) of the right hip shows prosthesis in good alignment and position. No evidence of loosening, fracture, or heterotopic ossification. Satisfactory post-operative appearance. **Assessment:** Patient is recovering well from right THA with good pain control and functional improvement. Surgical site is healing appropriately. No immediate complications identified. Patient is motivated and compliant with physiotherapy and home exercise program. **Plan:** Wound care: Keep site clean and dry. Continue paracetamol 1g QDS PRN for pain. Continue with prescribed physiotherapy and home exercise programme. Avoid hip flexion beyond 90 degrees, internal rotation, and adduction across the midline for the next 4 weeks. Gradually increase weight-bearing as tolerated and advised by physiotherapist. **Follow-up:** "A shared decision was made with the patient after discussion" Scheduled for a follow-up appointment in the orthopaedic clinic in 6 weeks (13 December 2024) with Dr. Thomas Kelly for clinical review and repeat imaging. Patient education provided regarding signs of infection and DVT, and when to seek urgent medical attention. Patient was informed about PIFU (Patient Initiated Follow Up) options if concerns arise before the scheduled appointment.