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Good Morning, I have to reply to this post.
Case Study
Chief Complain: “Right ankle pain.”
History of Present Illness (HPI): J. A is a 15-year-old male, accompanied by his mother, came
into the clinic complaining of right ankle joint pain and mild swelling for one day. The patient
reported yesterday while playing at football practice, he twisted his ankle while tackling an
opponent. He also reported he felt something like a tear. He reported constant pain of 4-5 out of
10. He reported walking makes the pain worse, and elevating the foot seems to improve some
but did not relieve his symptoms. He reported he did not take any over-the-counter or
prescriptive medication to help with pain. He denies any history of trauma to his extremities,
severe swelling, or deformity of the affected extremity.
Vital signs: B/P: 115/65; HR: 90; RR: 20; SPO2: 99% R/A; Temperature: 97.8 F (Orally);
Weight: 59.1 kg, Height: 170.2 cm. The child has no known drug, food, or environmental
allergy. General appearance: Awake, alert, oriented x3, appears calm, well nourished, and well-
groomed, sitting upright with the right lower extremity on the examination table. On physical
examination: Musculoskeletal: Tenderness at the lateral ankle, mild swelling, limited range of
motion, and no deformity noted.
Three HPI Questions
1. Are you having any pain? And if so, please describe the pain.
The description of multiple characteristics, such as pain location, whether localized or diffuse,
radiation, intensity, and aggravating and alleviating factors, is necessary to aid in diagnosis and
management.
2. Are you able to put any weight on the right foot?
If not, individuals suffering from serious injuries, such as those resulting from fractures of the
foot or ankle, are unable to bear any weight or use their feet, whereas individuals with mild foot
sprain can bear some weight-bearing and ambulate with assistance.
3. Is there any associated swelling or bruising of the foot? If so, where?
Torn and strained tissue, particularly ligaments, can result in swelling and bruising.
(Godoy-Santos & Schepers, 2019).
Three Review of System Questions
Neurological Musculoskeletal Skin
Numbness
Tingling
Burning Sensation
Weakness
Paralysis
Instability
Aches
Joint Pain (Rest, standing,
or walking)
History of trauma
(fracture/sprain/strain)
Deformity
Discoloration (Bruising)
Redness
Warmth
Swelling
Stiffness
History of bleeding disorder
Laceration
(Ömeroğlu, 2021).
Two Differential Diagnosis
Primary Dx: S93. 401A: Sprain of unspecified ligament of right ankle, initial encounter.
Two DDX:
1. M67. 873: Other specified disorders of tendon, right ankle and foot
2. S82: Fracture of lower leg, including ankle.
(Dains et al., 2020).
Diagnostic Test and Treatment
S93. 401A: Sprain of unspecified ligament of right ankle, initial encounter.
Diagnostic: (73552): A plain X-ray, such as 3 views of the affected joint: To determine any fracture of the
foot/ankle. Or (85025): CBC and (86551): ESR if an infection is suspected
MRI would be indicated if there is excessive swelling, pain, ecchymosis, or osteochondral
lesion/inadequate treatment
Treatment:
Pharmacological: Analgesics: non-steroidal anti-inflammatory drugs (Ibuprofen 400-800 mg PO Q6-8H with
food such as a snack or milk for 7-10 days).
Non-pharmacological: Limited weight bearing (rest), Ice (20 minutes on and 20 minutes off, 3-4 times a day),
for the first 48 hours, in addition to compression, brace, splint, elevation, and a healthy diet.
(Archangelo et al., 2022; Berkowitz, 2020).
Anticipatory Guidance & Education
Prior to education, assess patient/parents’ knowledge of the medication and misconceptions about the medication and
education on the new diagnosis
Advised limited activity and weight-bearing status
Advised on protective measures such as wearing the appropriate shoes or the use of braces.
Educate and advise the need for proper safety brief periods of warm-up, stretching exercises or slow range of motion
exercises as tolerated.
Advised the parents that the child can resume activity once the limb fully recovered, which may take 6-8 weeks.
Advised to keep adequate hydration
Ensuring the patient is up to date with vaccines and educated on the adherence to the immunization schedule.
Advised to adhere to the treatment plan and injury prevention.
Advised to return to the clinic if symptoms fail to improve or worsen or if after clinic hours to seek immediate
medical emergency to the nearest emergency department if symptoms are severe or call 911 if unable to go, such as
severe pain of 8-10 with 10 being the worse, unable to move extremity, numbness, tingling, severe swelling,
Advised to return to the clinic to follow up on the X-ray results in 7 to 10 days and the significance of keeping the
appointment.
Refer to Orthopedics if no improvement after 4-6 weeks or if acute fracture on X-ray.
(Berkowitz, 2020).
References
Archangelo, V.P., Peterson, A. W., Wilbur, V., & Reinhold, J.A. (2022). Pharmacotherapeutics for advanced practice: A practical approach. (5th Ed.)
Philadelphia, PA: Wolters Kluwer.
Berkowitz, C. D. (2020). Berkowitz’s pediatrics: A primary care approach (6th ed.). American Academy of Pediatrics.
Cho, D., Kukadia, S., & Drakos, M. (2023). Common football foot and ankle injuries: Non-surgical and surgical management. HSS Journal, 19(3), 1-13.
https://doi.org/10.1177/15563316231160458
Dains, J.E., Baumann, L.C., & Scheibel (2020). Advanced health assessment and clinical diagnostics in primary care (6th ed). Mosby Elsevier.
Godoy-Santos, A. L., & Schepers, T. (2019). Soft-tissue injury to the foot and ankle: Literature review and staged management protocol. Acta Ortopédica
Brasileira, 27(4), 223-229. https://doi.org/10.1590/1413-785220192704221240
Llopis, E., Ereño, M. J., & Martin, S. M. (2023). Imaging of the ankle and foot. Seminars in Musculoskeletal Radiology, 27(3), 229-230. https://doi.org/10.1055/s-
0043-1767807
Ömeroğlu, M. (2021). First step evaluation of patient with foot and ankle injury. Archives Medical Review Journal, 30(4), 185-208.
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