DIALOGUE

[doctor] hey matthew how're you doing
[patient] hey doc i'm doing pretty good how are you
[doctor] i'm doing pretty good hey i see here in the nurse's notes it looks like you hurt your left ankle can you tell me a little bit more about that
[patient] yeah i did my wife and i were on a walk yesterday and i was just talking to her and and stepped off the curb and landed on it wrong it's kind of embarrassing but yeah it's been killing me for a couple days now
[doctor] okay now when you fell did you feel or hear a pop or anything like that
[patient] i would n't say i really heard a pop it was just kind of really kind of felt extended and stretched and it it's just been really bothering me ever since kind of on the outside of it
[doctor] okay and then were you able to walk on it after the incident
[patient] i was able to get back to the house because i did n't wan na you know make my wife carry me but it was it was painful
[doctor] okay and then have you done any or had any injuries to that ankle before
[patient] nothing substantial that i would say in the past
[doctor] okay and then what have you been doing for that left ankle since then have you done anything to help make it make the pain less
[patient] i have taken some ibuprofen and then i just tried to elevate it and ice it a little bit and keep my weight off of it
[doctor] okay so let's talk real quick about your pain level zero being none ten being the worst pain you've been in in your life without any medication on board can you rate your pain for me
[patient] i would say it's about an eight
[doctor] okay and then when you do take that ibuprofen or tylenol what what's your relief level what's your pain look like then
[patient] maybe a seven it it's a little
[doctor] okay now you mentioned going for a walk my wife and i've been on on back behind the new rex center where the new trails are have you guys been back there
[patient] we have n't yet but i'm sure we'll check it out ever since i feel like working at home during covid we we we take walks all the time
[doctor] yeah i
[patient] no i have n't been there yet
[doctor] yeah those those trails are great there's like five miles of regular flat trails and then there's a bunch of hiking trails that they've opened up as well it's a really great place man you guys need to get out there we'll get you fixed up and we'll get you back out there okay
[patient] awesome
[doctor] so let's let's talk a little bit about my physical exam if it's okay with you i'm gon na do a quick physical exam on you your vitals look stable by the way a little elevated i know you're in pain on a focused exam of your left ankle now i do appreciate that there is ecchymosis or bruising over the lateral malleolus and there is some swelling i do i do appreciate some edema now you are positive for tenderness to palpation on the lateral side and the the soft tissue is swollen here the good news is i do not appreciate any laxity in the joint okay and i do n't feel any any type of bony tenderness to palpation of your foot now on the neurovascular exam of your left foot capillary refill is brisk less than three seconds and i do appreciate strong dorsalis pedis pulses and you do have motor and sensation intact which is good now it's important that they were compared bilaterally and they are yeah your your exam is the same bilaterally so that that's an important thing now we did do an x-ray of that left ankle when you came in so i'm gon na review those x-ray results with you now the good news is i do not appreciate a fracture or any bony abnormalities so that's a good thing right so let me talk to you a little bit about my assessment and plan so for your first problem of your left ankle pain your symptoms are consistent with an ankle sprain of the lateral ligament complex and the ligament on the outside of your ankle is what got stretched when you fell now the best treatment for this sprain is what you've kind of already been doing doing the elevation and compression and ice so we're gon na continue the rice protocol and i am gon na go ahead and give you an air cast just to stabilize that ankle i'm gon na prescribe you some crutches i want you to stay off that leg but i do want you to start walking as tolerated but it may be a few days before you feel like doing that now your symptoms are going to get better significantly over the first you know four five six seven days but i am gon na wan na follow up with you just to make sure you're doing okay so what i do is i would like to see you in two weeks and i'm gon na have you continue taking those nsaids as well to help reduce that pain and swelling any other questions comments or concerns before i have the nurse come in and get you fixed up
[patient] no i think that sounds like a plan
[doctor] okay sounds good like i said i will see you in two weeks if you have any questions or if you have a lot of pain come back in we'll reevaluate otherwise i think you're headed in the right direction and i'll see you again in two weeks
[patient] awesome thanks document
[doctor] alright thanks bye-bye

CLINICAL NOTE

CHIEF COMPLAINT

Left ankle pain.

HISTORY OF PRESENT ILLNESS

Matthew Murphy is a pleasant 20-year-old male who presents to the clinic today for the evaluation of left ankle pain. The onset of his pain began 2 days ago, when he stepped off of a curb and landed on his left ankle wrong. He denies hearing a pop at the time of the injury, however, he describes his ankle as feeling extended and stretched. He was able to ambulate back to his house after the incident but with pain. He denies any previous injuries to his left ankle. His pain is localized to the lateral aspect of his left ankle and can be rated at 8 out of 10 without medication. When taking ibuprofen his pain level is 7 out of 10. He states he has also iced and elevated his ankle.

SOCIAL HISTORY

Patient reports that he has been working from home since the start of COVID-19 and enjoys taking lots of walks.

MEDICATIONS

Patient reports taking ibuprofen.

REVIEW OF SYSTEMS

Musculoskeletal: Patient reports left ankle pain.

VITALS

Vitals are slightly elevated due to pain level but are otherwise stable.

PHYSICAL EXAM

NEURO: Normal strength and sensation bilaterally.
MSK: Examination of the left ankle: Ecchymosis noted over the lateral malleolus. Edema is present. Tenderness to palpation laterally. No joint laxity appreciated. No bony tenderness to palpation of the foot. Capillary refill is brisk at less than 3 seconds bilaterally. Strong dorsalis pedis pulses bilaterally.

RESULTS

These reveal no fracture or bony abnormalities.

ASSESSMENT

Left ankle sprain of the lateral ligament complex.

PLAN

After reviewing the patient's examination and radiographic findings today, I have had a lengthy discussion with the patient in regards to his current symptoms. We discussed that his symptoms are consistent with an ankle sprain of the lateral ligament complex. The nature of the diagnosis and treatment options were discussed. At this time he will continue to follow the RICE protocol. He will continue to take NSAIDs as needed for pain and swelling. He will also be placed into an Aircast for ankle stabilization and will be provided crutches in order to remain non-weight-bearing. We discussed that it may be a few days before he feels able to tolerate walking. I also advised him that his symptoms will likely start to improve significantly over the next 4 to 6 days.

INSTRUCTIONS

The patient will follow up with me in 2 weeks to assess his progress, sooner if needed.