CHIEF COMPLAINT: Right ankle pain.
HISTORY OF PRESENT ILLNESS: This is a (XX)-year-old Hispanic male who states that he was playing volleyball two days ago when he landed awkwardly on his foot. He is not sure if he inverted or everted his ankle. He heard a pop and now has pain with ambulation. He describes his pain as a 6/10 within the lateral aspect of his right ankle, worse with walking. Nothing seems to make it better or worse. Denies hitting his head or loss of consciousness.
PAST MEDICAL HISTORY: None.
ALLERGIES: None.
CURRENT MEDICATIONS: None.
FAMILY HISTORY: Noncontributory.
SOCIAL HISTORY: Positive for less than a half pack per day tobacco use. Negative for alcohol or drug use.
REVIEW OF SYSTEMS: Negative for fevers, chills, nausea, vomiting, diarrhea, constipation, headache, chest pain, shortness of breath or abdominal pain. All the systems are negative, except as noted in the HPI.
PHYSICAL EXAMINATION:
VITAL SIGNS: Blood pressure 132/78, pulse 76, respiratory rate 18, temperature 98.4 and pulse ox was 98% on room air.
GENERAL: The patient is awake, alert and oriented, in no apparent distress, resting comfortably on the bed.
EXTREMITIES: Full range of motion in all four extremities. No joint swelling or redness with the exception of his right lower extremity. In the area of the ankle, he has some swelling and tenderness over his right lateral malleolus. He has no pain with palpation over the proximal fifth metacarpal. He has no pain with palpation over the medial malleolus. No significant redness. He does have some bruising along the lateral aspect of his foot.
NEUROLOGIC: Neurologically, he is intact, moving all four extremities symmetrically and spontaneously with full motor strength. He has normal sensation to light touch.
SKIN: Warm and dry. No evidence or rash.
DIAGNOSTIC DATA: An x-ray of his right ankle shows no evidence of fracture or dislocation. No joint effusion.
EMERGENCY DEPARTMENT COURSE: The patient was seen and evaluated. He remained hemodynamically stable throughout his stay. He received two Percocets for relief of his pain. He was given an air splint and crutches and discharged from the emergency department.
MEDICAL DECISION MAKING: The patient presented with evidence of right ankle sprain. No evidence of fracture or dislocation at this time. He is able to ambulate, although with pain, so he will be sent home with crutches and an air splint. He is to follow up with Orthopedics if no better in one week. He has no evidence of any other concomitant injuries and is otherwise hemodynamically stable for discharge.
IMPRESSION: Right ankle sprain.
PLAN: As outlined above.
DISPOSITION: Discharged home in good condition.
