CHIEF COMPLAINT: Left foot pain.
HISTORY OF PRESENT ILLNESS: This is a (XX)-year-old Hispanic female who presents to the emergency department with left foot pain. The patient states that earlier this morning, she tripped missing a step, injuring her left foot. The patient states since then she has been unable to bear weight on that extremity. The patient cannot recall exactly what she hit her left foot on; however, she states the pain is unbearable. The patient describes this as a constant, throbbing ache rating it 8/10. The patient has not yet taken any pain medicine; however, she does have some at home because they came directly to the emergency department. The patient denies any head injury or loss of consciousness. The patient also denies any numbness or tingling of that extremity, decreased range of motion at the ankle, knee or hip. The patient does state she has seen an orthopedic physician in the past.
PAST MEDICAL HISTORY: Hypertension, depression, and multiple sclerosis.
CURRENT MEDICATIONS: Vicodin as needed, blood pressure pill, Lexapro, antibiotic, and a cough medicine.
ALLERGIES: NO KNOWN DRUG ALLERGIES.
SOCIAL HISTORY: The patient denies the use of tobacco and illicit or IV drugs and states she occasionally may have a glass of wine or some alcohol.
FAMILY HISTORY: Noncontributory.
REVIEW OF SYSTEMS: As stated above, otherwise negative per the patient.
PHYSICAL EXAMINATION:
VITAL SIGNS: Blood pressure 102/66, pulse 84, respirations 16, temperature 98.4, and O2 saturation 90% on room air.
GENERAL: This is a well-developed, well-nourished (XX)-year-old female who is alert and oriented x3 and appears to be in no acute distress. The patient is cooperative and communicates well.
HEENT: Normocephalic and atraumatic. Eyes: Equal, round, and reactive to light and accommodation. Extraocular movements are intact bilaterally. Conjunctivae are pink without discharge. Sclerae are anicteric. TMs appear clear. Buccal mucosa is pink and moist. Pharynx is without erythema or exudate.
NECK: Supple without lymphadenopathy. Trachea is midline.
LUNGS: Clear to auscultation bilaterally. No wheezing, rales or rhonchi noted.
HEART: Regular rate and rhythm. No murmur, rubs or gallops noted.
ABDOMEN: Soft, nondistended, and nontender to palpation in all four quadrants. Bowel sounds are present in all four quadrants.
EXTREMITIES: Distal pulses 2+ bilaterally. The patient has full range of motion in all extremities, however, is limited in range of motion of her left lower extremity secondary to pain. Sensation is intact to light touch. Upon further examination of the patient’s left lower extremity, she has 2+ dorsal pedis and posterior tibialis pulses with intact sensation. The patient has no pain with palpation over the fifth metatarsal nor over the great toe, however, does have pain with palpation over the dorsal aspect over the second, third, and fourth metatarsals. The patient does have a minimal amount of edema with some ecchymosis. The patient has no pain with palpation of the lateral medial malleolus and has an intact Achilles tendon. The patient has no pain with palpation over the tibia and fibula.
NEUROLOGIC: Cranial nerves II-XII are intact. DTRs are 2+ bilaterally of both upper and lower extremities. Muscle strength 5/5 of all extremities.
SKIN: Warm and dry to touch.
EMERGENCY DEPARTMENT COURSE: The patient was examined. At that time, an x-ray was ordered on the patient’s left foot, and it was negative for fracture or dislocation. However, it did show some soft tissue swelling. The patient was given one Vicodin p.o. here for her pain, which she tolerated well. The patient then had an Ace wrap to her left foot and was given crutches to aid with ambulation.
IMPRESSION: This is a (XX)-year-old female who presents to the emergency department with left foot pain after missing a step this morning. Upon examination, the patient had a small amount of soft tissue swelling. However, no fracture or dislocation was noted. At this point, we do feel the patient is stable for discharge home and does have an orthopedic physician that she can follow up with.
DIAGNOSIS: Left foot contusion.
PLAN:
1. Vicodin as needed for pain.
2. Rest, ice, elevation.
3. Follow up with Orthopedics for persistent symptoms.
4. Return for worsening symptoms.
DISPOSITION: The patient was discharged to home in stable condition.
