DATE OF ADMISSION: MM/DD/YYYY
CHIEF COMPLAINT: Left ankle pain.
HISTORY OF PRESENT ILLNESS: The patient is a very pleasant, otherwise healthy (XX)-year-old gentleman who was biking today. He said that he was getting off of his bike. He was stepping on the ball of his foot, when he felt that he hyperflexed his ankle and then he fell down. The patient states that he was wearing his helmet. He did not hit his head. He had no loss of consciousness. He did scrape his left ankle and his left knee, but his only real complaint is pain to his ankle. He states he was unable to bear weight immediately after the event, and here in the emergency room, he is complaining of a 4/10 mild sharp pain to the Achilles tendon of his left ankle, and he denies any other injuries.
PAST MEDICAL HISTORY: None.
ALLERGIES: None.
SOCIAL HISTORY: The patient denies any tobacco, alcohol or drugs. He is very active and bikes regularly.
REVIEW OF SYSTEMS: Musculoskeletal and constitutional as per HPI. Otherwise, 10-point review of systems was done and is negative.
PHYSICAL EXAMINATION:
GENERAL: The patient is well appearing. He is nontoxic. He is alert and oriented x4. GCS 15.
VITAL SIGNS: Blood pressure 126/76, heart rate 70, RR 18, temperature 37.2, and sat 99% on room air.
HEENT: Normocephalic and atraumatic. Pupils are equal, round, and reactive to light. Extraocular muscles are intact without any pain or diplopia. ENT: Tympanic membranes are benign with no hemotympanum. No Battle sign, no raccoon eyes, moist mucous membranes with benign oropharynx.
NECK: Supple. Full range of motion. No midline tenderness to palpation. No stepoff, no deformities.
LUNGS: Clear to auscultation bilaterally.
CHEST WALL: No crepitus. No flail chest. No tenderness to palpation.
HEART: Regular rate and rhythm. No murmurs, rubs or gallops.
ABDOMEN: Soft, nontender, and nondistended.
EXTREMITIES: The bilateral upper extremities and the right lower extremity are basically benign with no bony tenderness and full range of motion, though he has a small abrasion over the left elbow and a small abrasion over the left knee, but compartments are soft. Otherwise, skin is intact. In the left lower extremity, the patient has full range of motion at the hip and at the knee without any pain. He has passive full range of motion in the ankle; however, the patient cannot actively plantarflex, and he has a deficit in the deformity over the left Achilles tendon where he has some pain. DP pulses 2+. Sensation is intact to light touch. Compartments are soft.
NEUROLOGIC: Cranial nerves II through XII are grossly intact. Strength is 5/5 x4 extremities. Sensation is intact to light touch distally.
EMERGENCY DEPARTMENT COURSE: The patient was seen and examined. He had an x-ray done of his ankle. It was interpreted and then confirmed by Radiology. It was a three-view x-ray. There was no evidence of fracture, no evidence of dislocation, no soft tissue swelling. The patient did have a deficit to his Achilles tendon. He was unable to plantarflex, and therefore, it did appear that the Achilles tendon was injured. The patient was placed into a long leg lower extremity splint on the left. See the procedure note below.
PROCEDURE NOTE: Splint placement: Informed consent was obtained from the patient. All risks and benefits of the procedure were discussed as well as alternatives to care. We applied a long leg posterior splint to the patient’s left lower extremity with the ankle in plantarflexion using an Ace wrap to secure it. The patient was examined both before and after, and he was neurovascularly intact both times. The patient tolerated the procedure well. There were no complications.
MEDICAL DECISION MAKING: The patient is a very pleasant gentleman who had an injury to his left ankle. The differential diagnosis considered was a fracture, dislocation, or a soft tissue injury, including tendon injuries.
The patient had no evidence of fracture, dislocation; however, it did appear clinically that the patient has an Achilles tendon rupture. The patient was placed into a splint for comfort and immobilization. We discussed the case with the orthopedic service, and they state that the patient could follow up with them this week for likely surgical fixation.
DISPOSITION: Home.
CONDITION: Stable.
DIAGNOSIS: Achilles tendon rupture, left, and splint placement.
