SOLVED770
Emergency Department Record Chief Complaint: Right ankle injury History of Present Illness: The patient is 39-year old woman who injured her right ankle yesterday. While stepping around some puppies to avoid hitting them, she suffered an inversion injury to her ankle. She complains of lateral ankle and foot pain, and has pain on weight bearing. Past Medical History: Status post hysterectomy Medications: None Allergies: Codeine, which causes nausea Physical Examination: Alert female in no acute distress. Right lower extremity: proximal mid tibia-fibula are nontender. Ankle shows moderate diffuse swelling over the lateral ankle extending onto the dorsolateral foot with ecchymoses. Good distal neurovascular status. Decreased range of motion secondary to pain and swelling. Emergency Department: X-ray of right foot shows an avulsion fragment off the distal fibula. Course: Otherwise soft tissue swelling. Diagnosis: Acute right ankle sprain with avulsion fracture Disposition: Short leg splint applied. Crutches. No weight bearing. Ice and elevate. Vicodin #30 1-2q 4-6 h. She tolerates it well. Orthopedic referral. CPT Code(s): ___________________
SCIENCE
HEALTH SCIENCE
NURSING
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