SUBJECTIVE
Chief complaint and History of present illness: 24-year-old male presents to the clinic for complaints of left ankle pain. Patient was playing basketball when she laterally rolled ankle. Reports 10/10, sharp pain. Difficulty bearing weight. Denies numbness or tingling. Swelling and bruising but no open wounds. Event occurred 15 minutes before presentation to clinic and unable to take OTC analgesics.
Past medical history: No past medical history
Allergies: NKDA
Medications: No current home medications
Review of systems:
As noted in HPI.
OBJECTIVE:
Vital signs– Temp: 98.1 F, HR 88 bpm, BP 120/80, RR 18 resp/min, O2 sat 98% on room air
Exam:
CONSTITUTIONAL: This is a well-developed, well-nourished, adult female.
NEUROLOGICAL: Patient alert, orientated, memory intact. Dull and sharp sensation to bilateral feet present and equal bilaterally.
LUNGS: Respirations even and unlabored, chest expansion symmetrical.
MUSCULOSKELETAL/EXTREMITIES: Extremities are intact. Swelling and tenderness to lateral left ankle. Mild joint instability noted with passive range of motion of left ankle. Cap refill less than 3 seconds.
INTEGUMENTARY: Skin pink, dry, warm to touch. Ecchymosis to left ankle. No open wounds noted.
PSYCHOSOCIAL: Patient becomes tearful during exam but overall cooperative, interacts appropriately with staff.
Diagnostic test:
X-ray left ankle: Normal bone alignment. No sign of acute fracture. Read by myself.