Ankle Pain Emergency Room Transcription Sample Report
CHIEF COMPLAINT: Right ankle pain.
HISTORY OF PRESENT ILLNESS: The patient presents to the emergency room for evaluation of about a two-week history of right ankle pain. He initially fell into a small ditch. He states that he initially injured his left ankle; however, this has improved over the last couple of weeks. The left ankle pain improved, and he started to develop right ankle pain about a week ago. This has increased in severity over the last couple of days. He has followed with his primary care doctor who has apparently treated him with antibiotics and pain medications. This has helped to some degree, but he continues to have increased redness, warmth, and pain in the left ankle. He has not felt ill. He has had no fevers, chills or sweats. He has pretty significant pain with any weightbearing.
PAST MEDICAL HISTORY:
1. Coronary artery disease.
2. History of bypass.
3. History of heart failure.
4. Arthritis.
5. Some type of diabetes.
6. Hypercholesterolemia.
MEDICATIONS: Plavix, Proscar, Coreg, Lasix, Tricor, Coumadin, Lanoxin, Valium, Zocor, Vicodin, Proventil, and Amaryl.
The patient also has pills in his pocket; one says Percocet and one says Levaquin on it. He tells us that he has been taking these for the last several days.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: The patient denies alcohol, tobacco or illicit drug use.
FAMILY HISTORY: Noncontributory.
REVIEW OF SYSTEMS: As mentioned, otherwise negative.
PHYSICAL EXAMINATION:
VITAL SIGNS: Blood pressure 132/66, pulse 68, respirations 18, and temperature 97.4.
GENERAL: The patient is awake, alert, and oriented, in no acute distress.
HEENT: Normocephalic and atraumatic. Pupils are equal, round, reactive to light and accommodation. Extraocular movements are intact.
NECK: No lymphadenopathy. No carotid bruits. Neck veins are flat.
CHEST: Good breath sounds bilaterally with no wheezes, rales or rhonchi.
HEART: Regular rate and rhythm with no murmurs, rubs or gallops.
ABDOMEN: Soft, nontender, and nondistended. Good bowel sounds with no organomegaly.
EXTREMITIES: The patient has some increased warmth and redness on his left ankle, especially at the medial malleolus. He has only limited decreased range of motion in his left ankle. Range of motion in his toes and knee are normal. On the left, he has some swelling in the medial malleolar area as well. The right ankle appears normal and is normal with range of motion and palpation.
EMERGENCY DEPARTMENT COURSE: This patient was seen and evaluated for left ankle pain. It seems it has been going on for about two weeks and has had increasing symptoms within the last one week.
X-RAYS: X-ray of the ankle was done and was negative for acute fracture. It did show some soft tissue swelling at the area of the medial malleolus.
LABORATORY DATA: CBC was done and showed a white count of 11.8, H&H 14.6 and 44.6. BUN and creatinine were 42 and 2.2 respectively. His uric acid level was 9.1, which is high.
While he was still in the emergency room, we did speak with his primary care physician, as he was the one who sent him here to the emergency room and left a note to give him a call while the patient was still here. We did speak with him and filled him in on the radiologic and laboratory findings. He apparently was not given the patient’s history, whether the patient did not remember or it was not on his list we are not sure, but his primary care physician states that he had him on steroids recently in a rather big burst. He has been on pain medications and Levaquin for antibiotics. We decided to place him in a posterior splint and the primary care physician recommended Indocin for treatment of his gouty arthritis. We did fill him in on his creatinine being 2.2 and he was okay with that. He states that he will see the patient in followup.
DISCHARGE DIAGNOSIS: Acute gouty arthritis of the left ankle.
PLAN:
1. Indocin 25 mg three times a day until seen by primary care.
2. He should elevate the foot. He was placed in a dorsal splint. He is to maintain nonweightbearing status. We told this to him, as did the primary care physician apparently. However, the patient continues to try to weight bear when his family is not around. We gave him a quick low-purine diet and advised him to avoid alcohol, cheese, and other foods high in purines. He voices understanding. We told him to ask for more directions from his family doctor.
DISPOSITION: This patient was discharged to home in stable condition.
