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28 year old male / female, came to me because of pain in her right ankle since 2
days. Patient was brought in wheel chair / came walking with limp. Injury due to
twisting of the foot and ankle due to slip on the steps / fall while walking on
irregular surface. Initially mild to moderate pain and increased gradually. Aching
pain. Pain is continuous and more on walking. Mild swelling around anterior and
lateral ankle. Pain increasing with weight bearing. Radiation to the anterior and
lateral foot. No ecchymosis. No color change. No fever. No significant family
History. Social History -Employed. No chronic disease or known allergy. All other
systems reviewed and are negative
On examination of ankle:
Conscious and coherent patient who came in wheelchair / limping with antalgic
gait. On examination there was tenderness over and below the anterior and
lateral malleoli. Moderate oedema present. No tender ecchymosis. Restricted
ROM. Talar tilt test and Fibular compression test / Squeeze test –positive. External
rotation test and modified kleiger test – negative. Anterior drawer test is painful.
No deformity. No crepitus. No abnormal mobility. No redness. No raise of
temperature. Active toe movements present. Distal pulses felt
Pain & swelling of the left ankle after a Hx of twisting of the foot while playing in
school yesterday
The child is limping; Swollen Lt ankle & foot; Mild tenderness upon palpation of
the Lt medial malleolus; Mild limitation of the range of motion due to pain
Explained about the preliminary differential diagnoses and initial workup plan to
the patient.
X-ray: NAD
Plan:
Analgesics
Rest / SL 1 day
Non-weight bearing
Hot water fermentation/ ice wrapped the pack in a towel and apply for 15-20
minutes, 3 times daily.
Description:
Informed consent was obtained before procedure started. A non-medicated strap
applied from above the ankle to the toes in figure of 8 after applying soft roll for
the purpose of providing structural support, immobilization and compression for
the ankle and foot. Active toe movements advised. Elevation of the limb advised.
Description:
Analgesia
Sick leave
RICE
Description: