Problem: A 25 year old man presents to your office on a Tuesday Morning with ankle pain. He was playing in his usual Sunday Afternoon basketball game when he injured his right ankle. He jumped for a rebound and landed on another player's foot. His right ankle rolled over, and he fell to the floor. His ankle immediately started to hurt. He did not hear or feel a popping sensation. At the time, he was able to stand and walk with a limp, but was unable to continue playing. His ankle swelled over the next day in spite of rest, icing and elevation. On examination, he is a healthy appearing male with normal vital signs. The lateral aspect of the right ankle is swollen. The right ankle has normal dorsiflexion and plantar flexion, and there is no focal tenderness to palpation of the fibula, malleoli, or foot. No ligamentous laxity is noted on testing. He can bear weight with a small amount of pain. There is normal sensation and capillary refill in the foot. The remainder of the physical examination is normal.
Questions Are As Follows:
1. Subjective
2. Chief Complaint (CC):
3. History of Present Illness (HPI):
4. Past Medical History:
5. Family Medical History:
6. Social History:
7. Health Maintenance:
8. Allergies: NKDA
9. Medications:
10. Review of Systems:
- General:
- Head Eyes Ears Nose & Throat (HEENT):
- Neck:
- Pulmonary (Pulm):
- Cardiovascular (CV):
- Gastrointestinal (GI):
- Genitourinary (GU):
- Musculoskeletal (M/S):
- Neurologic (Neuro):
- Skin:
- Psychosocial (Psych):