DIALOGUE

[doctor] hey jean how're you doing today
[patient] i'm doing alright aside from this foot pain that i have
[doctor] so i see here that you looks like you hurt your left foot here where you were playing soccer can you tell me a little bit more about what happened
[patient] yeah so yeah i was playing in a soccer game yesterday and i was trying to steal the ball from another player and she ended up falling directly onto my right foot and i do n't know i i mean i was trying to get around her and my body ended up twisting around her and then i accidentally felt a pain in my foot
[doctor] okay so have you ever hurt your left foot before
[patient] no i've had a lot of injuries in soccer but never injured this foot
[doctor] okay and then so after the fall and the entanglement with the other player were you able to continue playing
[patient] no i had to stop playing right away and actually being helped off the field
[doctor] wow okay and what have you been doing for the the pain since then
[patient] so i've been keeping it elevated icing it the trainer wrapped it yesterday and taking ibuprofen as well
[doctor] okay alright so without any ibuprofen can you tell me what your pain level is
[patient] without ibuprofen i would say my pain is a three
[doctor] okay and then with your ibuprofen can you tell me what your pain level is
[patient] like a seven eight
[doctor] okay so how long have you been playing soccer
[patient] really since i was like four five i've been playing a long time
[doctor] well that's cool yeah we our our youngest daughter she is almost sixteen and she plays the inner marrial soccer league they are down at the rex center did is that where you started playing or did you guys did you start playing somewhere else
[patient] yeah just like this local town leak i started playing that way and then played all throughout school
[doctor] that's
[patient] high school teams
[doctor] that's awesome so just out of curiosity with the left foot have you experienced anything like numbness or tingling or or any strange sensation
[patient] no i have not
[doctor] okay now if it's okay with you i would like to do a quick physical exam i reviewed your vitals and everything looks good blood pressure was one eighteen over seventy two heart rate was fifty eight respiratory rate was fourteen you are afebrile and you had an o2 saturation of ninety nine percent on room air on your heart exam your regular of rate and rhythm do n't appreciate any clicks rubs or murmurs no ectopic beats noted there on auscultation listening to your lungs lungs are clear and equal bilaterally so you're moving good air i'd like to do a focused foot exam on your left foot so i do see some bruising on the bottom of your foot and on the top of your foot as well now there is associated swelling and i do appreciate tenderness to palpation of your midfoot and you are positive for the piano key test on a neurovascular exam of your left foot you have a brisk capillary refill of less than three seconds dorsalis pedis pulse is intact and strong and you do have motor and sensation that it's intact to light touch now i would like to do a review of the diagnostic imaging that you had before you came in so i do notice a subtle dorsal displacement of the base of the second metatarsal with a three millimeter separation of the first and second metatarsal bases and the presence of a bony fragment in the lisfranc joint space so lem me talk to you a little bit about my assessment and plan now for for the first concern of right foot pain your right foot pain is due to a lisfranc fracture which is a fracture to one of your second metatarsal bones at the top of your foot where the metatarsals meet your cuboids now there are ligaments at the top of your foot so i'm gon na be ordering an mri to assess for injury to any of these ligaments now based on your exam and from what i'm seeing on your x-ray you're most likely going to need surgery of that foot now the surgery will place the bones back in their proper position and using plates and screws will hold them there while they heal and this is gon na allow those bones and ligaments to heal properly it is a day surgery and you will be able to go home the same day and then i'm going to have you follow up with me here in the clinic you'll be in a cast and you will need to use crutches and you will not be able to use that left foot for about six to eight weeks now after that six to eight weeks you will gradually start walking on your foot based on how you tolerate it and we'll see how you do at that point so i do believe you're gon na need surgery i i'm recommending this because there are significant complications to your foot if we do not do this poor bone and ligament healing can lead to losing the arch of your foot and you're becoming flat-footed you also have a high likelihood of developing arthritis in that foot so what i'm gon na do unfortunately you'll be out the rest of the season but we are gon na get you fixed up and ready for next season if you're okay with all of this i'm gon na have the nurse come in and get you started on your paperwork and then i will see you on monday morning and we will get your foot taken care of
[patient] alright thank you
[doctor] you're welcome

CLINICAL NOTE

CHIEF COMPLAINT

Left foot pain.

HISTORY OF PRESENT ILLNESS

Jean Martinez is a pleasant 27-year-old female who presents to the clinic today for the evaluation of left foot pain.

The patient sustained an injury to her left foot while playing soccer yesterday. She became entangled with another player, causing the player to fall onto the patient's foot, resulting in immediate pain. After the incident, she required help to get off of the field and was unable to participate for the rest of the game. Her trainer wrapped her foot, and she has tried ice, elevation, and ibuprofen to treat her symptoms. with medication, she rates her pain as 3/10, but without medication her pain is rated as 7-8/10. There is no numbness, tingling, or other abnormal sensations associated with her pain.

Of note, the patient has sustained several injuries in the past while playing soccer, but this is her first left foot injury.

MEDICAL HISTORY

The patient reports that she has sustained several soccer injuries in the past.

SOCIAL HISTORY

The patient has been playing soccer since she was 4 or 5 years old. She is currently playing in a local league.

MEDICATIONS

The patient reports that she has been taking ibuprofen.

REVIEW OF SYSTEMS

Musculoskeletal: Reports left foot pain.
Neurological: Denies left foot numbness or tingling.

VITALS

Blood pressure: 118/72 mmHg
Heart rate: 58 bpm
Respiratory rate: 14
Temperature: Afebrile
Oxygen saturation: 99% on room air

PHYSICAL EXAM

CV: Regular rate and rhythm without clicks, rubs, or murmurs. No ectopic beats noted on auscultation of the heart. Brisk capillary refill, less than 3 seconds. Dorsalis pedis pulse is intact and strong.
RESPIRATORY: Lungs are clear and equal bilaterally.
NEURO: Motor and sensation in the left foot are intact to light touch.
MSK: Examination of the left foot: Ecchymosis on the plantar and dorsal aspects of the foot. Associated swelling. Tenderness to palpation of the midfoot. Positive piano key test.

RESULTS

X-ray images of the left foot were obtained and reviewed today. These reveal subtle dorsal displacement of the base of the 2nd metatarsal with a 3 mm separation of the 1st and 2nd metatarsal bases. There is presence of a bony fragment in the Lisfranc joint space.

ASSESSMENT

Lisfranc fracture, left foot.

PLAN

I explained the nature of her injury in detail. Based on her exam and x-ray findings, she will most likely require surgery of the left foot, but I want to order an MRI to assess for any ligamentous injuries. We discussed the procedure and postoperative expectations, such as recovery time and restrictions, at length. We also discussed the complications associated with deferring surgical intervention including poor bone and ligament healing, pes planus deformation, and a high likelihood of developing arthritis in the foot. She will be unable to participate for the remainder of the soccer season, but should be able to play next season.

INSTRUCTIONS

We will see the patient on Monday, for surgery.