History of Present Illness
Mrs. Smith is a 30 year old student seen at the request of Dr. Smith for the evaluation of ankle pain. She reports tripping over a rock in her front yard twisting her ankle. She noted a pop and severe pain in the ankle followed by rapid swelling and increase pain. She was taken by car to a local Emergency Room where xrays were reportedly normal. She was placed into an ankle stirrup and make weight bearing as tolerated. She followed up with her primary care physician who referred her for continued car. She notes continued severe pain and an inability to ambulate.
Pain Severity: /10 Pain location:
Pain at rest: /10 Exacerbating factors: activity
Pain with activity: /10 Ameliorating Factors: rest
Pain Duration:
Pain night:
Previous treatment:
PMH: none
PSH: none
Family History: Patient questionnaire was reviewed, signed and dated in the chart and was noncontributory.
Medications: none
Allergies: NKDA
Social History: no smoking, no alcohol use
ROS: Patient questionnaire was reviewed, signed and dated. Pertinent findings: no fevers, no chills, no drastic changes in weight, no known metal allergies.
Physical Exam
Height: Weight: Pulse: 80 BP:
General Appearance: Well-nourished, well developed in no acute distress
Orientation: Oriented to person, place and time. Mood / Affect: Calm
Gait: antalgic Coordination: normal
Elbow Exam (Bilateral)
Inspection/Palpation UE (R/L): Nontender, no effusion bilaterally
Elbow ROM (R/L): 0-135 / 0-135
Suppination (R/L): 80/80 Pronation (R/L): 80/80
Elbow Stability (R/L): no varus or valgus laxity bilaterally
Biceps (R/L): 5/5 / 5/5 Triceps (R/L): 5/5 / 5/5
Wrist Extension (R/L): 5/5 / 5/5 Wrist Flexion (R/L): 5/5 / 5/5
Intrinsics (R/L): 5/5 / 5/5
Sensation: Subjective normal median, ulnar, radial and axillary sensation bilaterally
Vasculature: 2+ radial pulse bilaterally
UE Skin (R/L): no rashes or lesions bilaterally
Lymph UE (R/L): no axillary lymphadenopathy
DTR UE (R/L): Biceps (2+/2+), Triceps (2+/2+)
Ankle Exam (Bilateral)
Inspection / Palpation LE (R/L): the right ankle is swollen and markedly tender both medially and laterally
Hindfoot Alignment (R/L):neutral / neutral
Dorsiflexion (R/L): 5º / 25º
Plantarflexion (R/L): 20º / 50º
Anterior Drawer (R/L): PF:(pain /0+), DF:(pain/0+)
Talar Tilt (R/L): Lateral:(pain /0+), Medial:(pain /0+)
Strength LE: 5/5 EHL, tibialis anterior, plantar flexion bilaterally
LE Skin: No rashes, no lesions
Lymph LE: no inguinal lymphadenopathy
Strength LE: 5/5 EHL, tibialis anterior, plantar flexion bilaterally
DTR LE: Patellar (2+/2+); Achilles (2+/2+)
Sensation: subjective normal distal sensation bilateral LE
Vasculature: 2+ dorsalis pedis bilaterally
Generalized ligamentous laxity: none
Diagnostic Studies
A/P, lateral and oblique views of the right ankle taken in the office today reveal the mortise in be intact with maintenance of the talotibial joint space. There are no fractures.
Assessment
Right Ankle Sprain
Plan
We discussed the natural history and both operative and non-operative treatment options. We discussed the risks, benefits and expected rehabilitative course of both operative and non-operative treatments. All questions were answered. Available links to further peer-reviewed written information on the diagnosis were provided. We will begin treatment with rest, ice, compression, and elevation (RICE) with early controlled motion in a functional brace or cam walker. She will progess with a home exercise program to improve proprioception and strengthening of the peroneal muscles. She will benefit from functional bracing for stenous/high risk activities in the future. She can weight bear as tolerated in the cam walker and will use a walker or crutches as needed. She will follow-up with us in 4 weeks for continued evaluation and management.
