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1-11 PATIENT NOTE: ANKLE PAIN HISTORY: Describe the history you just obtained from this patient.

Include only information (pertinent positives and negatives) relevant to this patients problem(s). HPI: 27 YO FEMALE C/O ANKLE PAIN SEVERE, SHARP W/O RADIATION 6/10 INTENSITY AND CONSTANT. BEGAN SUDDENLY SHE TRIPPED WHILE JOGGING. BRUISE AND SCRAPE TO R LATERAL MALLEOLUS WITH REDNESS AND SWELLING. AGGRAVATED BY MOVEMENT OR WALKING, ALLEVIATED WITH TYLENOL. DENIES FEVER, BOWEL OR BLADDER CHANGES , NO PREVIOUS EPISODES OB/GYN: LMP NORMAL, LPS NORMAL, NO PREGNANCIES ROS: NEGATIVE EXCEPT AS NOTED ABOVE ALLERGIES: NKDA MEDS: NONE PMH: NONE PSH: NONE FH: PARENTS ALIVE AND WELL SH: DENIES TOBACCO, ETOH, DRUG USE LIVES WITH HUSBAND AND TWO CHILDREN PHYSICAL EXAM: Describe any positive and negative findings relevant to this patients problem(s). Be careful to include only those parts of examination you performed in this encounter. THE PATIENT IS VERY ANXIOUS AND VITALS ARE WITHIN NORMAL LIMITS. HER HEAD AND NECK APPEAR NORMOCEPHALIC AND ATRAUMATIC. HER NECK IS SUPPLE WITH NO LYMPHADENOPATHY AND THYROID IS WITHIN NORMAL LIMITS. HER HEART SOUNDS ARE NORMAL WITH S1/S2. HER BREATH SOUNDS ARE CLEAR TO AUSCULTATION BILATERALLY. HER ABDOMEN IS SOFT, NONTENDER AND NONDISTENDED WITH BOWEL SOUNDS HEARD. HER RIGHT ANKLE IS SWOLLEN AND TENDER OVER THE LATERAL MALLEOLUS WITH ECCHYMOSIS. UNABLE TO CHECK THE ROM OR MOTOR STRENGTH DUE TO PAIN. THE LEFT ANKLE SKIN APEEARS NORMAL WITH NO TENDERNESS. THERE WAS FULL DORSIFLEXION AND PLANTAR FLEXION, EVERSION AND INVERSION OF THE LEFT ANKLE. THE STRENGTH OF THE LEFT FOOT WAS 5/5 AND PULSES WERE NORMAL THROUGHOUT WITH SENSATION INTACT BILATERALLY. DATA INTERPRETATION: Based on what you have learned from the history and physical examination, list up to 3 diagnoses that might explain this patients complaint(s). List your diagnoses from most to least likely. For some cases. Fewer than 3 diagnoses will be appropriate. Then, enter the positive or negative findings from the history and physical examination (if present) that support each diagnosis. Lastly, list initial diagnostic studies (if any) you would order for each listed diagnosis (e.g. restricted physical exam maneuvers, laboratory tests, imaging, ECG, etc. DIAGNOSIS #1: FRACTURE ANKLE

HISTORY FINDING(S) - h/o trauma, fell while jogging - severe, sharp pain, 6/10 intensity - pain aggravated by movement

PHYSICAL EXAM FINDING(S) - swollen, red tender over lateral malleolus - ecchymosis

DIAGNOSIS #2: SPRAIN ANKLE/CELLULITIS HISTORY FINDING(S) PHYSICAL EXAM FINDING(S) - h/o trauma, fell while jogging - swollen, red tender over lateral - severe, sharp pain, 6/10 intensity malleolus - pain aggravated by movement - ecchymosis DIAGNOSIS #3: GONOCOCCAL ARTHRITIS HISTORY FINDING(S) PHYSICAL EXAM FINDING(S) - female of reproductive age - swollen, red tender over lateral - severe, sharp pain malleolus - pain aggravated by movement - ecchymosis DIAGNOSTIC STUDIES: - PELVIC EXAM WITH GC, CHLAMYDIA CULTURE - URINE HCG - X-RAY OF RIGHT ANKLE - CBC - GRAM STAIN AND CRYSTAL ANALYSIS

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