CHIEF COMPLAINT: Right ankle injury.
HISTORY OF PRESENT ILLNESS: This is a (XX)-year-old Hispanic female with a history of depression who states that she missed steps into a hole this evening. She describes it as inversion injury to her ankle. She now complains of lateral ankle pain and swelling that has been progressively worsening. She states she did take ibuprofen around 7:30 with good pain control. She has been ambulatory since this happened. She denies paresthesias, numbness, coldness or weakness in the extremity. She reports worsening pain with range of motion and with weightbearing. She denies any other injuries, including head trauma, neck or back pain or injuries to the remaining extremities. She is currently rating her pain as a 6/10 in severity. It is a constant aching pain, slightly improved with elevation and with ice. Her pain does not radiate. She otherwise has no complaints.
PAST MEDICAL HISTORY: Depression.
MEDICATIONS: Zoloft.
ALLERGIES: None.
FAMILY HISTORY: Not elicited.
REVIEW OF SYSTEMS: As stated above in the HPI. Significant for right lateral ankle pain and swelling, status post trauma, associated with decreased range of motion and weightbearing. She has otherwise been well.
PHYSICAL EXAMINATION:
VITAL SIGNS: Blood pressure 138/78, pulse 100, respirations 18, temperature 98.2, and pulse oximetry on room air is 100%.
GENERAL: This is a well-developed and well-nourished Hispanic female in no acute distress. She is alert and oriented x3.
EXTREMITIES: Focused examination of the right lower extremity exhibits no gross deformity or ecchymosis. She does have marked soft tissue swelling noted at the lateral ankle with significant tenderness to palpation to the lateral malleolus. There is no other focal bony tenderness noted medially with palpation to the toes, foot, lower leg or knee. She has negative Thompson test. DP and PT pulses are present and equal bilaterally with brisk capillary refill in all five digits. Sensation is intact to light touch and pinprick in all five digits. She is able to wiggle her toes without difficulty. Range of motion of the foot and ankle is limited secondary to her pain, and stability is not assessed. She has full range of motion at the knee with no evidence of effusion and no joint line tenderness. The extremity is otherwise unremarkable.
SKIN: Warm, dry, and intact.
EMERGENCY DEPARTMENT COURSE: The patient was given ibuprofen 800 mg p.o. per her request. She had an x-ray of the right ankle, which was reviewed by the radiologist showing an oblique lateral malleolar fracture and widened ankle mortise consistent with ligamentous disruption as well as subtalar joint widening and an avulsion fracture of the navicular. Dr. John Doe saw the patient and agrees with the assessment and plan. She was placed in a sugar tong and posterior short leg splint and provided crutches and given copies of her x-rays.
DIAGNOSIS: Right ankle fracture.
PLAN:
1. The patient is given fracture and splint instructions.
2. The patient is to follow up with Orthopedics.
3. The patient is to avoid weightbearing and use her crutches.
4. The patient is to return to ED for numbness, coldness in the toes or any worsening symptoms.
5. The patient is given a prescription for Vicodin to take as directed for severe pain. She is told not to drive with this.
6. The patient is to rest, ice, and elevate the extremities as much as possible.
DISPOSITION: The patient is discharged to home in good condition and ambulated out of the department without difficulty with the assistance of her crutches.
