VER

VER - AI software utilized for scribe purposes. Pt/representative aware and agreeable. History: Issue #1: Acute Ankle Sprain -Patient is a 32-year-old semi-professional footballer who presents with acute right ankle pain following an injury during training approximately 2 hours prior to arrival. This is his first significant ankle injury. -He describes an inversion injury where his foot landed awkwardly after a jump, immediately causing sharp pain on the outside of his right ankle. He heard a 'pop' sound at the time of injury. -Pain is localized to the lateral malleolus and anterior talofibular ligament (ATFL) region. Severity is rated 7/10 at rest, increasing to 9/10 with any attempt at weight-bearing. Pain is throbbing. -Applying ice immediately after the injury provided some temporary relief, but pain returned once the ice was removed. He attempted to walk off the field but was unable to bear weight. -Swelling developed rapidly within the first 30 minutes post-injury. He notes significant difficulty with dorsiflexion and plantarflexion due to pain. -Impact on daily activities is significant, as he cannot walk or put any weight on the right foot. He is concerned about his upcoming match. -Associated symptoms include swelling, bruising (developing), and tenderness to touch. -No headache, no chest pain, no shortness of breath. Issue #2: Mild Headache -Patient reports a mild, diffuse headache that started this morning, prior to the ankle injury. He attributes it to insufficient sleep. Severity 3/10, relieved slightly by paracetamol earlier. Past Medical History: -CPP reviewed -No significant past medical history. No previous fractures or major injuries. -Home medications: None. OTC medications: Occasionally takes paracetamol for minor aches. -Immunization history: Up-to-date with routine adult vaccinations. -Social history: Non-smoker, occasional social alcohol use (1-2 units per week), no recreational drug use. Occupation is professional athlete. -Allergies: NKDA RN's Physical Examination: -Vital signs: BP 120/78 mmHg, HR 72 bpm, RR 16 breaths/min, Temp 36.8°C, O2 Sat 99% on room air. -Right ankle: Significant swelling and ecchymosis over the lateral malleolus and anterior aspect of the ankle. Tenderness to palpation over the ATFL and calcaneofibular ligament. ROM severely limited due to pain, especially inversion and plantarflexion. Anterior drawer test and Talar tilt test positive for pain and laxity. Unable to bear weight. Distal pulses present and strong, capillary refill <2 seconds. Sensation intact. No deformity noted. Issue #2: Mild Headache: -No focal neurological deficits. Pupils equal, round, reactive to light and accommodation. No nuchal rigidity. Investigations: -No investigations completed at this stage. Impression: Issue #1: Acute Ankle Sprain -Likely high-grade lateral ankle sprain (grade II or III), given the mechanism of injury, rapid swelling, significant pain, inability to bear weight, and positive ligamentous stress tests (anterior drawer, talar tilt). Differential includes fibular fracture, talar dome fracture, or syndesmotic injury, which require imaging to rule out. Issue #2: Mild Headache -Tension-type headache, likely multifactorial (sleep deprivation, stress). Management Plan: Issue #1: Acute Ankle Sprain -Investigations planned: Right ankle X-rays (AP, lateral, mortise views) to rule out fracture. -Treatments planned: RICE (Rest, Ice, Compression, Elevation). Provide crutches for non-weight bearing. NSAIDs (ibuprofen 400mg TDS PRN for pain). -Counselling, referrals, lifestyle advice, or other actions taken: Educated patient on RICE protocol. Discussed potential rehabilitation post-injury and importance of adherence to prevent recurrence. Referral to physiotherapy will be considered upon imaging results. Issue #2: Mild Headache -Advised rest and hydration. Continue paracetamol as needed. Monitor for worsening symptoms. -Return to care instructions: Return immediately if experiencing increasing pain, numbness/tingling, colour changes in foot/toes, fever, or signs of infection.