Initials: N.T, Age: 46 years, Sex: Female, Race: White
S.
CC ” I have pain in both ankles”
HPI: N.T. is a forty-six-year-old white female patient who reported to the facility for a check. She complains of pain in both her ankles, even though she expresses more concern with the right ankle. The patient was playing soccer during the weekend when she heard a pop sound, which led to uncomfortable pain. The patient also experienced swelling following the pop sound. Consequently she is also unable to bear her weight. The pain is throbbing and more concentrated on the right ankle. She also rates the pain while resting. The pain is also radiating up the right lower extremity.
Current Medications: The patient is not using any medication currently.
Allergies: There are no records of allergies to food, medication, or environment.
PMHx: The patient indicated that she took her full dose of COVID-19. All other immunizations and annual flu tests are up to date.
Soc Hx: The patient is currently a single parent with three children. She works in the hotel industry. She likes playing soccer, which she does mostly during weekends but also occasionally in the evenings. She denies the previous or current use of alcohol. She also denies smoking or use of other illegal drugs.
Fam Hx: The patient’s parents are still alive; the father is eighty years old, and the mother is seventy-seven years old. The father is living with diabetes and hypertension while the mother has been treated for depression before and is currently living with osteoporosis. She has one elder brother and a younger sister and both are fairly healthy with no major health concerns.
GENERAL: No fatigue, weakness, chills, fever, and weight loss.
HEENT: The patient’s head is normal; No visual loss, blurred vision, or double vision. She also denies reduced hearing, sneezing, congestion, sore throat, or even runny nose.
SKIN: No signs of rash, itching, or bruising.
CARDIOVASCULAR: No chest discomfort, chest pain, or pressure. Denies palpitations or edema.
RESPIRATORY: The patient denies any shortness of breath, sputum, or cough.
GASTROINTESTINAL: The patient denies anorexia, nausea, vomiting, or abdominal pain.
GENITOURINARY: No burning or pain during urination. She denies pregnancy. NEUROLOGICAL: She denies headache, dizziness, paralysis, ataxia, or numbness.
MUSCULOSKELETAL: She reports bilateral ankle pain. The pain is more concentrated on the right ankle as compared to the left ankle. She also reports swelling in the right ankle and is unable to bear her weight.
HEMATOLOGIC: No anemia or bleeding.
LYMPHATICS: No history of splenectomy; denies enlarged nodes.
PSYCHIATRIC: No history of headache or mental illness.
ENDOCRINOLOGIC: No Polydipsia or polyuria.
ALLERGIES: No known allergies, either to food, medication, or environment
O.
Vital signs: BP: 116/75, Temp: 97.0, RR: 18, HR: 76, Height: 6.2, Weight: 141 lbs
General: The patient is well-dressed and groomed. She is alert and oriented. She appears concerned regarding her ankle pain which started after hearing a pop sound when playing soccer during the weekend.
HEENT: The head is atraumatic and Normocephalic. No ear pain or discharge. No loss of vision, no runny or stuffy nose. The patient’s neck is supple.
Skin: The skin is warm and dry, with no wounds and no skin rashes. Bruising was seen in the right lateral ankle.
Chest: The heartbeat and heart rate are both regular, with no gallops, murmurs, or extra sounds. No cough or dyspnea. The patient’s lungs are clear.
The musculoskeletal system: The patient’s right ankle has bruises, and the fibula’s lower aspects are tender upon palpation. Less motion range was observed in the ankles. The swelling was also observed. Pain experienced on the leg when bearing weight. The left ankle had no bruising, swelling, or tenderness.
Diagnostic results: The Ottawa Ankle rule is to be used to help determine if the patient needs an X-ray to confirm or rule out a fracture (Morais et al.,2021). Ultrasound can be conducted to assess the structure of the soft tissues such as ligaments and tendons.
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