DATE OF SERVICE: MM/DD/YYYY

CHIEF COMPLAINT: Right index finger injury from a week ago.

HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old right-hand dominant male who injured his right index finger almost a week ago when he cut it while using a pocket knife. The pocket knife evidently buckled, cutting the dorsum of his right index DIP joint. He was aware that the digit dropped in flexion at the DIP joint, and he was unable to extend this.

The patient was evaluated at an outside hospital where his wound was sutured. He was referred to this facility for followup care of a tendon injury. The patient is accompanied by his wife on this visit today. He reports minimal discomfort associated with the injury. He denies numbness or tingling of the digit, however.

PAST MEDICAL HISTORY: Pertinent for asthma and hypertension.

PAST SURGICAL HISTORY: None.

MEDICATIONS: Atenolol, diazepam, and fluticasone.

ALLERGIES: Multiple medication allergies, listed in the chart.

SOCIAL HISTORY: This is a (XX)-year-old married male who lives with his wife and one child. The patient smokes a pack of cigarettes daily. He denies drug and alcohol use.

REVIEW OF SYSTEMS: The patient denies any cardiorespiratory symptoms, including chest pain, palpitations, shortness of breath, wheezing, coughing, fever, chills or malaise.

PHYSICAL EXAMINATION:
GENERAL: The patient is a well-appearing (XX)-year-old male who is alert and oriented, in no acute distress.
HEART: Heart rate of 60 with a regular rate and rhythm without murmur, rub or gallop.
LUNGS: Clear to auscultation.
EXTREMITIES: Focused examination of the right index finger demonstrates a 1 cm transverse wound across the dorsal DIP joint. The wound has almost completely healed. There are three residual nylon sutures, which are all removed today. There is no localized erythema, induration, swelling or tenderness. There is an extensor lag of approximately 20 degrees at the DIP joint. There is full passive extension of the distal phalanx at the joint. There is mild hyperextension at the PIP joint.

IMPRESSION AND PLAN: This is a (XX)-year-old right-hand dominant male, now almost one week out from a laceration to the dorsal right index finger with injury to the terminal extensor tendon.

All of this was discussed today with the patient. The case was reviewed today with Dr. John Doe who recommends closed reduction, percutaneous pinning, and repair of the terminal extensor tendon. The patient is agreeable to having this done.

The potential risks and complications associated with the procedure were reviewed and discussed today with the patient. He was cautioned that due to the unstable nature of the tendon in this area that repair is very difficult and sometimes not completely successful, and that he may, as a result of this injury, end up with a mild permanent flexion at the DIP joint. He was cautioned that the pin will need to remain in place for upwards of six to eight weeks and that he will be required to work on hand therapy upon pin removal.

The patient verbalized understanding and acceptance of all of this. Informed consent was obtained. The patient was re-placed today into a radial gutter splint. Arrangements will be made to have this done next week.

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PREOPERATIVE DIAGNOSES:
1.  Rheumatoid arthritis.
2.  Genu valgum.
3.  Degenerative joint disease of the knee.
4.  Attenuated medial collateral ligament.

POSTOPERATIVE DIAGNOSES:
1.  Rheumatoid arthritis.
2.  Genu valgum.
3.  Degenerative joint disease of the knee.
4.  Attenuated medial collateral ligament.

OPERATION PERFORMED:
1.  Total knee arthroplasty.
2.  Medial collateral ligament reconstruction.

SURGEON:  John Doe, MD

ANESTHESIA:  General.

FINDINGS AND DESCRIPTION OF OPERATION:  The patient was taken to the operating room and anesthesia administered. After adequate anesthesia, the patient was prepped and draped in a sterile manner. An anterior incision was made sharply through the skin and subcutaneous tissue. Dissection was performed on the medial retinaculum of the patella and a quad incision then made. The patella was retracted. The patellofemoral ligament was then incised. Dissection was performed anteriorly initially. No medial release was performed, but dissection at the edge of the medial collateral ligament was accomplished. Initially, a lateral release was performed. Longitudinal incision was made at the patellar retinaculum between the patella and the femur longitudinally to the fat. Dissection was then performed sharply to the tibia and 1 cm above the tibia anteriorly and posteriorly. All soft tissues anterior to the patient’s lateral collateral ligament were incised, and lateral collateral ligament was protected. The patient’s release was gauged and then the patient’s tibia cut was made. Care was taken to ensure minimal resection and to allow for restoration of the normal alignment. A 90-degree cut was made. The patient had significant trough made in the lateral posterior plateau. It was felt that augmentation may be necessary; however, with further balancing and bone resection at the tibia, augmentation was not necessary.

The patient’s distal femoral cut was made, normal amount, with balance at the appropriate center of rotation, followed by anterior and posterior cuts. Care was taken to ensure proper rotation, which did require some adjustment secondary to the hypoplastic lateral femoral condyle. The epicondylar access was utilized as a guide as well as Whitesides line. Although the patient had significant tracking laterally, Whitesides line was not felt to be accurate, so epicondylar access was key and was utilized. Further balancing was required. With the complete lateral resection, the thought was to either lengthen the lateral collateral ligament or recess the medial collateral. Recession was then performed at the medial collateral ligament. This involved identifying the epicondyle on the medial side, paying close attention to the attenuated medial collateral ligament. Once the structure was identified, #2 FiberWire was passed through it, and drill holes were placed. A punch was then utilized to allow for tunneling and sliding of the bone was performed. It was then tied over a button laterally. The trial reduction was made and then insert used that was smaller and then it was balanced in this manner.

The femoral cuts were made and Marcaine was injected, followed by placement of the cement. It had been mixed and was tacky and doughy. It was then placed over the tibia, tibial component placed and then the femoral component and patella. Knee was extended and then the tibial insert was exchanged after medial collateral ligament was tightened. Very good stability accomplished with equal flexion and extension gap to varus and valgus stress. The patient tolerated the procedure well and was then transferred to the recovery area where neurovascular exam revealed normal peroneal nerve function.

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CHIEF COMPLAINT:  Bilateral knee pain.

HISTORY OF PRESENT ILLNESS:  This is an (XX)-year-old Hispanic female patient, who was brought in by her father this evening with a complaint of bilateral knee pain secondary to a fall while playing soccer. The patient states that she just remembers hitting the ground hard with her knees. She did not feel anything pop or hear anything. She says that the crowd was too loud, and she could not hear anything. The patient has been unable to bear weight on the left leg since the injury. She states that this is the worse of the two. She complains of swelling and also some abrasions on both knees. No numbness or tingling or decrease in sensation. The patient has increased pain with range of motion. The patient states there was no loss of consciousness with the fall.

PAST MEDICAL HISTORY:  Asthma.

ALLERGIES:  NKDA.

CURRENT MEDICATIONS:  Albuterol and St. John’s wort.

SOCIAL HISTORY:  The patient is a nonsmoker.

REVIEW OF SYSTEMS:  The patient has had no fever or chills, no loss of consciousness, no numbness or tingling. Review of systems is otherwise negative.

PHYSICAL EXAMINATION:
VITAL SIGNS:  Temperature 98.2 degrees, pulse 84, respirations 18, blood pressure 122/76, and pulse oximetry is 100% on room air.
GENERAL:  This is an (XX)-year-old Hispanic female patient, who is awake and alert. The patient is semi-reclined on the gurney, appears to be resting comfortably, nontoxic.
EXTREMITIES:  Upon examination of the right knee, there is some mild edema. No ecchymosis or erythema. Small abrasions over the patellar region. She has some small amount of edema over the anterior portion of the knee. She has pain and tenderness with palpation and increased pain with range of motion. She had a negative anterior and posterior drawer test. Negative Lachman. She had good pedal pulse, brisk capillary refill. The Achilles tendon is intact. Skin is warm, dry, and intact. On examination of the left knee, there are multiple small abrasions over the anterior knee, edema over the anterior knee, with exquisite tenderness with palpation, all of the surrounding area of the knee. She had a negative anterior and posterior drawer test. Negative Lachman. She had increased pain with Apley’s test with downward pressure and rotation of the foot. The patient has a good pedal pulse and brisk capillary refill. Skin is warm, dry, and intact. Achilles tendon is intact. She has increased pain with attempts of range of motion.

DIAGNOSTIC TESTS:  X-rays were done of both knees, four views each. Interpreted by Dr. Jane Doe, in the absence of Radiology, as negative for fracture or dislocation.

PROCEDURES:  Knee immobilizer was applied to the left knee. It was re-examined by Dr. Jane Doe. It was well placed. The extremity was neurovascularly intact. She was also given crutches and one Tylenol No. 3 here in the ER.

CONSULTATIONS:  None.

IMPRESSION:
1.  Right knee pain.
2.  Left knee pain, rule out cartilage tear.

DISCHARGE INSTRUCTIONS:
1.  RICE.
2.  Prescription for Tylenol No. 3, one to two p.o. every four hours p.r.n., #20 given.
3.  Follow up with Dr. John Doe in two to three days.
4.  Return for increased pain, fever, redness, swelling, decreased sensation or other concerns.

DISPOSITION:  The patient was released in good condition.

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CHIEF COMPLAINT: The patient is a (XX)-year-old male coming in complaining of right leg pain.

HISTORY OF PRESENT ILLNESS: The patient states that he was in a fight approximately two weeks ago and scratched up his right lower leg. Since then, he has been going and visiting hot springs. The patient noticed that the site that was previously healing well was now turning red and appeared to be swelling. Pain was continuing to get worse. The patient tried to self-lance and was having more pain now. He also reports limited motion in the right knee due to pain. Pain is 10/10, nonradiating, and constant. Nothing makes it better or worse. Associated limited range of motion in the right knee. No fever. No malaise.

PAST MEDICAL HISTORY: None. No history of steroid use. No history of liver problems.

ALLERGIES: NO KNOWN DRUG ALLERGIES.

SOCIAL HISTORY: The patient admits smoking marijuana. Denies any other drug use such as cocaine or methamphetamines. Denies smoking.

MEDICATIONS: None.

REVIEW OF SYSTEMS:
CONSTITUTIONAL: No fever or malaise.
HEENT: Eyes: No change in vision. Ears: No change in hearing. Nose: No epistaxis or rhinorrhea. Mouth: No sore throat.
NECK: No neck stiffness.
CARDIOVASCULAR: No history of cardiac disorders. No chest pain.
RESPIRATORY: No difficulty in breathing. No cough.
GASTROINTESTINAL: No nausea, vomiting, diarrhea, or abdominal pain.
MUSCULOSKELETAL: Swelling below the right knee but not in the right knee. No other joint swelling.
NEUROLOGIC: The patient reports normal sensation and slight numbness in the right foot but states that he can move the right foot without difficulty and feels palpation.
DERMATOLOGIC: Positive swelling below the right knee laterally, getting larger per the patient.

PHYSICAL EXAMINATION:
VITAL SIGNS: Blood pressure 150/86, heart rate 90, respiratory rate 20, O2 sat 99% on room air, and temperature 98.6 orally.
GENERAL APPEARANCE: Alert and oriented x3. No apparent distress. Appears well.
HEENT: Eyes: Pupils equal, round, and reactive to light. Extraocular muscles are intact. Ears: Normal external exam. Nose: No epistaxis or rhinorrhea. Mouth: Normal oropharynx.
NECK: Supple. Nontender.
HEART: Regular rate and rhythm without murmur.
LUNGS: Clear to auscultation bilaterally.
ABDOMEN: Soft and nontender to palpation. Positive bowel sounds.
EXTREMITIES: The patient is holding the right knee at 45 degrees flexion. Unable to straighten it due to pain, but the knee itself does not appear swollen. There is no fluctuance of the knee or any other joint.
NEUROLOGIC: The patient reports decreased sensation in the right foot. Otherwise, no focal weakness. No other decreased sensation.
SKIN: There is an area of erythema approximately 8.5 cm x 4.5 cm over the proximal fibula that extends up into the lower portion of the knee but does not cover the knee. There is no palpable fluctuance. There is an area that clearly is where the patient was self-lancing. The area is very taught and excruciatingly tender to the patient.

EMERGENCY DEPARTMENT COURSE: The patient was given morphine 10 mg IV for pain. Blood cultures were sent. X-rays of the tib-fib were obtained as well as the knee, which appear normal. The patient received Toradol. The patient is now able to extend the knee. The patient received Rocephin 1 gram and doxycycline in the ER. The patient received a CBC, which shows 14,200 white count with left shift. BMP is normal.

CONSULTS: Dr. John Doe has come and seen the patient and agrees to I&D the patient, as well as admit the patient for IV antibiotics.

FINAL DIAGNOSIS: Abscess/cellulitis of the right lower leg.

DISPOSITION: Admitted.

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REQUESTING PHYSICIAN: John Doe, MD

REASON FOR CONSULTATION: Left total hip arthroplasty.

HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old right-handed woman with history of osteoarthritis of both hips, left side worse than right, with increasing pain and decreased ability to ambulate. The patient was admitted to the hospital, and she underwent a left total hip arthroplasty. There have been no postoperative complications. She is getting fairly good pain relief with her medications. She is starting to eat. She did not sleep that well last night.

PAST MEDICAL HISTORY: Osteoarthritis of the right hip. No major medical problems. Tonsillectomy as a child. D&C as a teenager.

ALLERGIES: NONE.

MEDICATIONS: Metamucil one package daily with water, OxyContin 10 mg q. 12 hours, Coumadin 5 mg daily, and oxycodone IR 5 mg q. 3 hours p.r.n. for pain.

MEDICATIONS PRIOR TO ADMISSION: Naprosyn, which she had not taken for 10 days prior to surgery, Prevacid p.r.n., calcium, glucosamine, Tylenol, vitamin C, and vitamin E.

DIET: Advance as tolerated.

FUNCTIONAL STATUS: The patient has a Foley catheter. Her last bowel movement was yesterday before her surgery. She requires setup for feeding. She requires setup for grooming from the seated position. She requires assistance for dressing, bathing, and toileting. She requires assistance for bed mobility, transfers, and ambulation. She was ambulating without assistive device prior to admission.

SOCIAL HISTORY: The patient is married. The patient works part time. She does not smoke. She does not drink. She lives in a two-level home with 14 stairs up to the bedroom and full bathroom. There is a small bathroom on the first floor.

FAMILY HISTORY: The patient’s mother died from a stroke at the age of 86. Her father is alive in his 90s. She has breast cancer.

REVIEW OF SYSTEMS: Per the HPI and PMH. She is hard of hearing bilaterally. She has a hearing aid on the left. She wears glasses. Hepatitis, possibly due to hormone replacement therapy, which was stopped.

PHYSICAL EXAMINATION:
VITAL SIGNS: Temperature 98.4, pulse 84, respirations 16, and blood pressure 112/60. Height 5 feet. Weight is 130 pounds.
GENERAL APPEARANCE: A well-developed, well-nourished woman who is in no acute distress. Her affect is normal. Her husband was present during the interview on examination.
HEENT: NC/AT.
NECK: Without bruits.
LUNGS: Clear.
HEART: Regular rate and rhythm without murmur.
ABDOMEN: Bowel sounds are positive, soft, nontender, and nondistended.
EXTREMITIES: No clubbing, cyanosis, or edema. No calf erythema, warmth, or tenderness. Peripheral pulses are strong and symmetrical. Passive range of motion was within functional limits throughout, except not tested at the left hip. The surgical incision was dressed and it was not inspected.

NEUROLOGICAL EXAMINATION: The patient is alert and oriented x3. She did not demonstrate any gross cognitive or language deficits. Cranial nerves II through XII were intact, except she was hard of hearing bilaterally. Tone was normal. No atrophy was noted. Strength was normal in all four extremities, except for 3/5 at the left hip and knee. Sensory exam was grossly intact. Coordination was intact in the upper extremities. Ambulation was not tested at this time.

LABORATORY DATA: Hemoglobin 9.4, sodium 130, potassium 3.6, and INR 1.02. Preoperative hemoglobin was 12.9.

ASSESSMENT:
1.  Left total hip arthroplasty.
2.  Osteoarthritis of the right hip.
3.  Impaired mobility and self-care.
4.  Postoperative anemia.
5.  Hyponatremia.
6.  Hard of hearing bilaterally.

PLAN:  Physical and occupational therapies are pending. The patient is appropriate for some type of rehabilitation, as she has many stairs to negotiate at home. Her Foley catheter will be removed per orthopedic protocol. The assessment and recommendations were discussed with the patient’s husband.

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SUBJECTIVE:  The patient is seen in followup regarding his right knee injury. He is approximately three months status post right quadriceps tendon repair. He has been wearing a hinged knee brace, which has been unlocked. He has been receiving outpatient physical therapy. At the present time, overall, he is doing quite well. He has no pain.

OBJECTIVE:  On examination of the right knee, the skin is examined. The skin is intact. Surgical incision is well healed. There is no knee effusion. There is no soft tissue swelling. The foot is warm and well perfused with brisk capillary refill. Motor and sensory functions are intact distally. Passive range of motion is from full extension to 135 degrees of knee flexion. Arc motion is pain-free. The knee is stable to varus valgus stress testing. There is mild quadriceps muscle atrophy. His gait is examined. It is nonantalgic in nature.

ASSESSMENT AND PLAN:  Right quadriceps tendon rupture. The diagnosis was reviewed in detail with the patient. At the present time, overall, he is doing quite well clinically. We will discontinue the hinged knee brace. He will continue with outpatient physical therapy to work on range of motion and strengthening exercises as well as endurance. He is allowed to return to work, light duty, no heavy lifting. He will need frequent rest periods. We will see him back in three months’ time for repeat clinical evaluation. No x-rays needed at that time.

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DATE OF SERVICE:  MM/DD/YYYY

SUBJECTIVE:  The patient returns. This is a gentleman who underwent a decompression and instrumented fusion of L3-L5. He is very satisfied with the result, seemed to have done well in terms of relieving his leg pain. He has developed an underlying lymphoma. He is being treated for that with chemotherapy. He is getting flare-ups of back pain, seems to be localized to his back, does not seem to radiate down his legs. No numbness or tingling in his toes. This has become bothersome to him. It waxes and wanes. When it bothers him, he rests. He is not sure what brings it on and what makes it better.

OBJECTIVE:  On exam, he stands with a level pelvis, is compensated. The paraspinal musculature is soft. When asked to forward flex, could do so cleanly to 70-80 degrees, side bend 10-20, extend 10. Trendelenburg sign is negative. Heel toe gait is preserved. Lower extremity motor is 5/5 throughout. Reflexes at knees and ankles are trace at the knees, 1+ at the ankles. Sensation is diminished across both feet, that is he cannot tell sharp from dull.

ASSESSMENT AND PLAN:  We think he has got a neuropathy. We will obtain new radiographs and review them. We have given him Robaxin for pain at his request. He is advised regarding the side effects. We will see how he fares.

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DATE OF SERVICE:  MM/DD/YYYY

SUBJECTIVE:  The patient is here for followup of her left knee. She has got some significant patellofemoral arthrosis. Also has some tricompartmental arthritis seen on an arthroscopy. It has really curtailed her activities. She inquired about Synvisc-One injection. We have gotten approval for that.

OBJECTIVE:  There is just a trace effusion today. She has got moderate patellofemoral crepitus, 0 to about 120. Positive flexion pain. Collaterals intact. Neurovascularly intact.

New x-rays were obtained today and compared to films from about a year and a half ago showing a mild progression of osteoarthritic changes in the patellofemoral joint in particular, but also slightly more so medially.

ASSESSMENT AND PLAN:  Knee osteoarthritis. Discussed treatment options. She wants to go forward with the Synvisc-One shot. We discussed risks, including but not limited to infection and adverse reaction to the Synvisc. She expressed good understanding and requested that it be done.

The left knee was prepped sterilely with Betadine and alcohol. Superolateral portal site was used to enter the knee under sterile technique with a 20-gauge needle injecting 6 mL of Synvisc. She tolerated it well.

We will see her back p.r.n. We discussed the possibility of the knee arthroplasty if this does not help her sufficiently.

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DATE OF SERVICE:  MM/DD/YYYY

SUBJECTIVE:  The patient returns to Orthopedic Clinic today for followup evaluation of left shoulder partial infraspinatus and anterior labral tear. She is doing very well. She has been doing physical therapy since I last saw her, and her pain is completely resolved. She also reports she feels much stronger.

OBJECTIVE:  On examination today, she has full range of motion of the left shoulder. Negative Hawkins, Neer, cross-arm. Symmetric 5/5 strength on resisted internal and external rotation, thumbs down, supraspinatus, and lift-off testing.

ASSESSMENT:  Clinically improved left rotator cuff impingement and pain.

PLAN:  At this point, we have told her to progress gradually to a gym program. She can give me a call if her pain were to return, but we did recommend one Aleve by mouth twice daily and then to give us a call if she would have any worsening pain. We do not anticipate that her rotator cuff tear will progress to a full-thickness tear; however, once again, if she were to have any return of pain, she should come and see me immediately.

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DATE OF SERVICE:  MM/DD/YYYY

SUBJECTIVE:  The patient is here followup on her ankle sprain. She really has no pain. She has been working on her balance exercises, and this has made a big difference for her.

OBJECTIVE:  Her drawer sign is negative. She has no tenderness over ATFL and medial ligamentous complex. She does have a punctate area of numbness around the level of the medial talonavicular joint. This makes sense based on her mechanism of injury and showed her foot was stepped on.

ASSESSMENT AND PLAN:  The patient has made excellent recovery from her right ankle sprain. We have advanced her into full activities, and we will follow up with her on an as-needed basis.

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DATE OF SERVICE:  MM/DD/YYYY

SUBJECTIVE:  The patient presents in followup regarding his orthopedic injuries. He is approximately four weeks status post right and left quadriceps tendon repairs. He has been in hinged knee braces locked in extension. He is to weight bear as tolerated. His wounds have healed. Overall, he is doing quite well. He is at a rehabilitation facility.

OBJECTIVE:  On examination of the right and left lower extremities, the wounds are healed. There are no local signs of infection. There is no soft tissue swelling, ecchymosis, or edema. There is bilateral quadriceps muscle atrophy. There is no calf pain, swelling or tenderness to palpation. He is able to perform straight leg raises against gravity bilaterally. Passive range of motion is from full extension to approximately 45 degrees of flexion on both sides. Radiographs were not performed today.

ASSESSMENT AND PLAN: Five weeks status post right and left quadriceps tendon repairs. The diagnosis was described in detail to the patient. At the present time, his knee braces can be unlocked. He will continue to weight bear as tolerated, and we will have the therapist begin to work on active range of motion, active assisted range of motion, passive range of motion, and progressive resistive exercises. We would like to see him back in five weeks’ time for repeat clinical evaluation. No x-rays will be needed at that time.

Ortho Operative Sample Reports

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DATE OF SERVICE:  MM/DD/YYYY

SUBJECTIVE:  The patient describes the ability to basically subluxate both of his shoulders, although it is not painful. However, recently, it has started to hurt. He denies any other issues. He is right-hand dominant.

OBJECTIVE:  He is a well-nourished, well-developed male, in no acute distress. Normal affect. Skin is intact. He has a good range of motion, symmetric; about 185 degrees of forward elevation, external rotation to 60. Internal rotation is a little bit less on the right than the left to the low thoracic and midthoracic spine. He had a little bit of winging of the scapula. He has a negative O’Brien and negative dynamic labral shear. He has a little bit of a click with load and shift anteriorly, but he does not feel it, and he does not have any pain. He has negative apprehension and negative Jobe test. He otherwise is neurovascularly intact.

X-rays are negative.

ASSESSMENT AND PLAN:  At this point, we are going to get him into a formal physical therapy program. We spent a good time talking about his shoulder. We went over the sleeper stretch and other exercises. We talked about avoiding things that aggravate it. Certainly, if he has recurrent subluxations or any dislocations, we will go ahead and get an MR arthrogram. For now, we will get him into therapy. We will see him back in a month for a recheck. He will call in the interim with any troubles.

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HISTORY OF PRESENT ILLNESS:  This is a (XX)-year-old Hispanic male who states that he was playing volleyball two days ago when he landed awkwardly on his foot. He is not sure if he inverted or everted his ankle. He heard a pop and now has pain with ambulation. He describes his pain as a 6/10 within the lateral aspect of his right ankle, worse with walking. Nothing seems to make it better or worse. Denies hitting his head or loss of consciousness.

PAST MEDICAL HISTORY:  None.

ALLERGIES:  None.

CURRENT MEDICATIONS:  None.

FAMILY HISTORY:  Noncontributory.

SOCIAL HISTORY:  Positive for less than a half pack per day tobacco use. Negative for alcohol or drug use.

REVIEW OF SYSTEMS:  Negative for fevers, chills, nausea, vomiting, diarrhea, constipation, headache, chest pain, shortness of breath or abdominal pain. All the systems are negative, except as noted in the HPI.

PHYSICAL EXAMINATION:
VITAL SIGNS: Blood pressure 132/78, pulse 76, respiratory rate 18, temperature 98.4 and pulse ox was 98% on room air.
GENERAL: The patient is awake, alert and oriented, in no apparent distress, resting comfortably on the bed.
EXTREMITIES: Full range of motion in all four extremities. No joint swelling or redness with the exception of his right lower extremity. In the area of the ankle, he has some swelling and tenderness over his right lateral malleolus. He has no pain with palpation over the proximal fifth metacarpal. He has no pain with palpation over the medial malleolus. No significant redness. He does have some bruising along the lateral aspect of his foot.
NEUROLOGIC: Neurologically, he is intact, moving all four extremities symmetrically and spontaneously with full motor strength. He has normal sensation to light touch.
SKIN: Warm and dry. No evidence or rash.

DIAGNOSTIC DATA:  An x-ray of his right ankle shows no evidence of fracture or dislocation. No joint effusion.

EMERGENCY DEPARTMENT COURSE:  The patient was seen and evaluated. He remained hemodynamically stable throughout his stay. He received two Percocets for relief of his pain. He was given an air splint and crutches and discharged from the emergency department.

MEDICAL DECISION MAKING:  The patient presented with evidence of right ankle sprain. No evidence of fracture or dislocation at this time. He is able to ambulate, although with pain, so he will be sent home with crutches and an air splint. He is to follow up with Orthopedics if no better in one week. He has no evidence of any other concomitant injuries and is otherwise hemodynamically stable for discharge.

IMPRESSION:  Right ankle sprain.

PLAN:  As outlined above.

DISPOSITION:  Discharged home in good condition.

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