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How To Write A Post-Operative Report

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This report is being submitted early to include the first post operative visit information. On 3/20/17 I met Ms. Iversen at the office of Dr. Nwuso. Ms. Iversen arrived with a cam boot on the right foot and also with crutches. She was applying little weight to the foot. She reports that she has pain from the cam boot on her incisions. Ms. Iversen reported that she came back to see Dr. Nuswo about a week after her surgery because she felt her dressing were wet from drainage. There apparently was no drainage. Ms. Iversen had a list of questions for Dr. Nwuso. Her questions were confusing and Dr. Nwuso was getting frustrated. He told her from his stand point she can do anything she wants. She is not going to rip open the incision or do anything to the fractures. They are healed and stable. T …show more content…

He told her that she will have some pain and swelling for up to a year. He wants her to wear compression stockings, get back into physical therapy and be fitted for a lace up brace. The sutures to the outer and inner aspect of the ankle were removed. She feels pressure and rubbing from everything on the incisions. Dr. Nwuso told her to stop using the crutches, do not use a cane, and let physical therapy wean her out of the cam boot. When asked for work status, Ms. Iversen said she could not work with a boot or a limp. Finally Dr. Nwuso wrote for her to start with restrictions and work no more than 8 to 14 hours per week. He will advance them as she deems necessary. She will follow up in 6 weeks, on 5/1/17. I asked how her back was doing and she said it was fine. She has completed physical therapy and is doing a home exercise program. She is worried that her cervical spine was damaged. She has a prior issue with her neck. I asked her if her neck is worse or the same than it was. She said it was the same but worries something

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