physical examination
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Patient Information: CC : A 46-year-old female reports pain in both of her ankles, but she is more concerned about her right ankle. She was playing soccer over the weekend and heard a “pop.” She can bear weight, but it is uncomfortable. In determining the cause of the ankle pain, based on your knowledge of anatomy, what foot structures are likely involved? What other symptoms need to be explored? What are your differential diagnoses for ankle pain? What physical examination will you perform? What special maneuvers will you perform? Should you apply the Ottowa ankle rules to determine if you need additional testing?
Initials, N/A Age, 46 Sex, Female Race, not indicated
CC: Bilateral Ankle pain
HPI: Pt c/o bilateral ankle pain, worse on R s/p hearing a “pop” while playing soccer this past weekend. Pt is able to bear weight, with some discomfort and was more concern about her R ankle.
Location: Bilateral ankle
Onset: Over the weekend
Character: Bilateral ankle pain, worse on the right. She was playing soccer over the weekend and heard a “pop.”
Associated signs and symptoms: She can bear weight, but it is uncomfortable
Timing: over the weekend and heard a “pop. “while playing soccer
Exacerbating/ relieving factors: She can bear weight, but it is uncomfortable
Severity: She can bear weight, but it is uncomfortable
Current Medications: Not indicated
Allergies: None indicated
PMHx: None indicated
Soc Hx: played Soccer over the weekend
Fam Hx: None Indicated.
GENERAL: No weight loss, fever, chills, weakness or fatigue indicated
HEENT: Eyes: PERRLA, no visual impairment blurred vision, double vision or yellow sclerae indicated. Ears, Nose, Throat: No hearing loss, sneezing, congestion, runny nose or sore throat indicated
SKIN: No rash or itching nor discoloration indicated
CARDIOVASCULAR: No chest pain, chest pressure or SOB. No palpitations or edema indicated
RESPIRATORY: No shortness of breath, cough or difficulty breathing indicated
GASTROINTESTINAL: No anorexia, nausea, vomiting or diarrhea. No abdominal pain or blood indicated
GENITOURINARY: No Burning on urination. No indication of Pregnancy. Last menstrual period not indicated.
NEUROLOGICAL: No headache, dizziness, syncope, paralysis, ataxia, numbness or tingling in the extremities. No change in bowel or bladder control indicated
MUSCULOSKELETAL: bilateral ankle pain, worse on R. Positive pulses on both dorsalis and pedis bilaterally. Right ankle with 1+edema, erythema; and tenderness on palpation noted. No edema or erythema noted on the left ankle.
HEMATOLOGIC: No anemia, bleeding or bruising indicated
LYMPHATICS: No enlarged nodes. No history of splenectomy.
PSYCHIATRIC: None indicated
ENDOCRINOLOGIC: No reported
ALLERGIES: NkDA
Peripheral Vascular: Right ankle with 1+edema, erythema; and tenderness on palpation noted. No edema or erythema noted on the left ankle Positive pulses on both dorsalis and pedis bilaterally.
Assessment:
Additional questions
More needed questions may include
Point exactly where your pain is?
What’s your pain scale on 0-10, o no pain and 10 being the worst?
