CHIEF COMPLAINT: Ankle injury, left.
HISTORY OF PRESENT ILLNESS: This (XX)-year-old female presented to the emergency department this evening for evaluation of injury to her left ankle, which she suffered yesterday evening.
The patient apparently suffered an inversion injury to her left ankle when she stepped awkwardly off of a step down onto pavement. She notes some pain with active range of motion of the ankle as well as with weightbearing and ambulation.
She apparently went to work today and was noted to have some difficulty with ambulation and so was instructed to present here for evaluation and treatment of her injury.
REVIEW OF SYSTEMS: The patient denies any fever, chills, nausea, vomiting or diarrhea. She denies any obvious bony deformity, ecchymosis or hematoma to the left ankle, foot or digits. She does note some soft tissue swelling to the lateral aspect of the ankle without erythema, crepitus or increased joint warmth to the same. She notes pain with active range of motion of the ankle, otherwise denies numbness, tingling or paresthesias to the same or muscle weakness.
REVIEW OF SYSTEMS: Otherwise negative as pertains to chief complaint.
Nursing notes reviewed.
PAST MEDICAL HISTORY: None.
PAST SURGICAL HISTORY: None.
CURRENT THERAPY: Vitamins.
ALLERGIES: None.
IMMUNIZATION HISTORY: Not applicable.
SOCIAL HISTORY: The patient is a nonsmoker. Denies substance/alcohol abuse.
PHYSICAL EXAMINATION:
VITAL SIGNS: Temperature 98.6, pulse 76, respirations 20, BP 114/72, pulse oximetry 97% on room air.
GENERAL: A well-developed, well-nourished, nontoxic, ambulatory (XX)-year-old female.
MENTAL STATUS: The patient is alert and oriented x4.
MUSCULOSKELETAL: Focused musculoskeletal exam reveals tenderness, soft tissue swelling to the lateral malleolus of the left ankle. There is no obvious bony deformity, bruising or soft tissue swelling noted. There is no erythema, crepitus or increased joint warmth noted as well. She is ambulatory with a stable but antalgic gait, otherwise exhibits strong distal pedal pulses, brisk capillary refill in all digits of the left foot.
NEUROLOGIC: Reveals no gross motor/sensory deficits. The patient is alert, cooperative and exhibits intact distal sensation in all digits of the left foot.
INTEGUMENTARY: Without diaphoresis, rash, lesions. Skin is warm and dry to touch. Normal tone and turgor.
DIAGNOSTIC DATA: A 3-view x-ray of the patient’s left ankle revealed no evidence of fracture, dislocation or other bony abnormality as reported by radiologist.
EMERGENCY DEPARTMENT COURSE: The patient’s left ankle placed in an Ace wrap prior to the patient’s discharge. She has otherwise been stable throughout her stay in the emergency department.
MEDICAL DECISION MAKING: We discussed this patient’s case with Dr. John Doe who also evaluated the patient and agreed with the final diagnosis of a left ankle sprain and the treatment plan that follows.
CONSULTATIONS: None.
IMPRESSION: Left ankle sprain.
PLAN:
1. Rest, ice, compress, elevate.
2. Over-the-counter ibuprofen, up to 600 mg 3 times daily with food as needed for pain and swelling.
3. Follow up with primary care provider in 3 to 4 days if not improving or return to the emergency department for any worsening symptoms or new concerns.
The patient voiced agreement with this final diagnosis and treatment plan. She voiced clear understanding of the instructions.
DISPOSITION: Discharged to home in good condition.
