Case Study Todd Reilly

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CHIEF COMPLAINT: Status post ORIF of the tibial plateau on the left.

HISTORY OF PRESENT ILLNESS: This patient is new to me. He was treated by Todd Reilly, MD with ORIF. He was seen in followup by David Lin, MD. The patient comes today for a wound check and staple removal. He states he still gets some throbbing, moderate to severe pain, particularly with movement.

PHYSICAL EXAM: Notes that it was too painful to do a stability test, but the incision is clean, dry, and well approximated with retained staples. There are no signs of infection. The foot is neurovascularly intact.

IMAGING: Notes that the posterior fragment remains displaced from the post-operative film. There appears to be no change. Appears to be [_1:34___]mild

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