Initials: M.D. Age: 46 years old Sex: Female Race: Caucasian
S.
CC (chief complaint): Case 2: Ankle Pain
HPI: The patient is a 46-year-old Caucasian female experiencing pain in both ankles. She expresses more concern regarding her right ankle due to a “popping” sensation experienced during a recent football match. She experiences discomfort while putting weight on her right ankle. The patient reports experiencing intermittent achy and throbbing pain on the outer side of their right ankle. The patient reports a pain level of 4/10 at rest and 7/10 during ambulation. After the injury, she applied elevation and ice to her right ankle. She has used ibuprofen sporadically to alleviate pain, yielding moderate outcomes. The pain sometimes spreads about 4 inches along the outer side of the right lower limb. The right ankle experienced immediate swelling following a popping sound. She occasionally experiences discomfort in her left ankle, with a pain rating of 3-4 out of 10. However, there are currently no sudden changes in the condition of her left ankle.
Location: ankles
Onset: About three days ago, during the weekend.
Character: The pain sometimes spreads about 4 inches along the outer side of the right lower limb.
Associated signs and symptoms: The right ankle experienced immediate swelling following a popping sound.
Timing: All day long
Exacerbating/ relieving factors: Tylenol and ice packs may help lessen the discomfort. With weight on it, it is worse.
Severity: Reports a pain level of 4/10 at rest and 7/10 during ambulation.
Allergies: No reported allergies to drugs, food, or latex.
PMHx: She undergoes an annual flu vaccination. She has received the COVID-19 vaccination. The individual received all childhood immunisations as recommended and received a tetanus booster in 2018. Her depression is effectively managed with Effexor. One caesarean section was performed.
Soc Hx: The patient is married and has a 13-year-old child. She works as a cashier at a nearby nursery. She exhibited athleticism during her childhood. She abstains from smoking, drinking, and using recreational drugs. She maintains her physical well-being by engaging in regular football matches with friends and weightlifting exercises thrice a week. She consumes a single cup of coffee daily. She follows a plant-based diet. She has maintained a vegetarian diet for a decade.
Fam Hx: The patient’s 80 mother is alive and healthy. Her medical history includes severe arthritis in her joints, depression, and hypertension. The father, aged 83, is currently in good health despite having a history of malignancy in his prostate, unspecified mental health disorders, hypertension, and high cholesterol. She has a 54-year-old brother who is alive and in good health, although he has undiagnosed mental health disorders. Her 14-year-old son is in good health. The health history of the deceased grandparents includes arthritis, lung cancer, prostate cancer, hypertension, cirrhosis related to alcoholism, and high cholesterol.
GENERAL: denies experiencing weakness, exhaustion, or fever.
HEENT: denies experiencing headaches or changes in taste, smell, vision, or hearing.
SKIN: denies rashes, itching, superficial bruises, or inadequate wound healing.
CARDIOVASCULAR: denies experiencing any chest pressure, pain, or discomfort. No edema or palpitations. Denies orthopnea and paroxysmal nocturnal dyspnea. Denies intolerance for exercise.
PERIPHERAL VASCULATURE: denies having blood clots, calves discomfort, easy bruising, or a history of aneurysms.
MUSCULOSKELETAL: Affirms right ankle edema, trouble bearing weight, and bilateral ankle discomfort worse on the right than on the left. She disputes any previous joint stiffness, bony abnormalities, or restricted range of motion in any joint, including bilateral ankles.
NEUROLOGIC: denies having ever had a CVA, headaches, vertigo, concussion, seizures, numbness, or tremors.
MENTAL HEALTH: reports a history of well-controlled depression. She says her mood is steady. Denies having trouble focusing, mood fluctuations, or disturbed sleep.
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Vital signs: BP 129564, HR 71, RR 18, and temperature were all at 97.9 F on room air. Weight- 123 pounds, 5’5″ in height. BMI: 20.5
General: Ankle pain in the right leg is the only source of minor discomfort for this 46-year-old Caucasian woman. She is kind and helpful.
HEENT: The head appears normal in size and shape, with no signs of injury. The patient’s examination findings include PERRLA and EOMI.
Skin: Warm and dry. No observed skin abnormalities, such as rashes, wounds, lesions, or excessive bruising. The right lateral ankle exhibits bruising.
Neck: Flexible. Complete range of motion.
Chest: Lungs are clear upon auscultation. The patient does not exhibit any coughing or difficulty in breathing. Normal heart sounds, S1 and S2, are present without abnormal sounds such as murmurs, rubs, or gallops. No edema was observed except for the right lateral ankle.
Peripheral vasculature: The dorsal pedis pulses on both sides are graded as +2, as are the posterior tibial pulses, popliteal pulses, and femoral pulses bilaterally.
Musculoskeletal System: The right lateral ankle is swollen and exhibits a reduced range of motion, weakness, and tenderness upon palpation of the lower aspect of the fibula and the surrounding ligaments (including the anterior and posterior tibiofibular ligaments, posterior and anterior talofibular ligaments, and calcaneofibular ligament), as well as the lateral malleolus. The right ankle exhibits bruising on its lateral aspect. The medial aspect of the right ankle is non-tender and does not exhibit any bony deformities or bruising. The left ankle does not exhibit any swelling, bruising, or overt tenderness upon palpation. There were no observed deformities or limitations in the range of motion of the toe, knee, hand, or finger joints. The spine is in a straight position. The patient exhibits weight-bearing ability on the right foot, albeit with pain. Pain disrupts gait.
Diagnostic results: A right ankle radiograph will be performed if the Ottawa ankle rules indicate it is necessary. An ankle ultrasound will be conducted if it is indicated. Stress tests will be administered to both ankles if they are indicated.
A.
Primary Diagnosis: Right ankle inversion sprain
Hertel, J., & Corbett, R. O. (2019). An Updated Model of Chronic Ankle Instability. Journal of Athletic Training, 54(6), 572–588. https://doi.org/10.4085/1062-6050-344-18
Lee, J.-H. (2020). Short-Term Effect of Ankle Eversion Taping on Bilateral Acute Ankle Inversion Sprains in an Amateur College Football Goalkeeper: A Case Report. Healthcare, 8(4), 403. https://doi.org/10.3390/healthcare8040403
Malfait, F., Colman, M., Vroman, R., De Wandele, I., Rombaut, L., Miller, R. E., Malfait, A., & Syx, D. (2021). Pain in the Ehlers–Danlos syndromes: Mechanisms, models, and challenges. American Journal of Medical Genetics Part C: Seminars in Medical Genetics, 187(4), 429–445. https://doi.org/10.1002/ajmg.c.31950
Morimoto, S., Tachibana, T., & Tomoya Iseki. (2023). Avulsion fracture of the calcaneal tuberosity treated with novel surgical technique using the combination of the side-locking loop suture technique and ring pins: a case report. Journal of Surgical Case Reports, 2023(4). https://doi.org/10.1093/jscr/rjad173
van Dijk, P. A. D., Kerkhoffs, G. M. M. J., Chiodo, C., & DiGiovanni, C. W. (2019). Chronic Disorders of the Peroneal Tendons. Journal of the American Academy of Orthopaedic Surgeons, 27(16), 590–598. https://doi.org/10.5435/jaaos-d-18-00623