Painful Ankle Medical Treatment - Case Study Example

Patient B.Age: 51 years old male.Patient comes alone and gives own health and personal history. The patient also sign the consent form on his own and consents to examination and any necessary care. The patient comes walking with a level of difficulty. The patient is not sick-looking, communicates with ease and freely.PC: The patient complains of a swollen and painful ankle (Kaufman 2008, p. 2396).HPC: The patient has been running after a cow that had broken out of the shed when his left foot got stuck in a trench and he fell spraining his left ankle.

Attending the department for examination and care.PMH: patient admitted once at the age of 16 years with appendicitis (Dealey 2012, p. 199). Appendectomy done.No major illness since childhood.Weight: 76kgMedications: The patient has been on analgesics broad-spectrum antibiotics regimen that ended three days ago; provided at the clinic. No other medication currently.Allergies: The client has a specific protein food allergies, cannot eat eggs. There is no known drug allergies.Immunisation: Tetanus injection immediately after the cut (one week ago) scheduled for a repeat (booster) in three weeks’ time (Greaves and Johnson 2002, p.38).SH: the patient is married, living with the wife and two children.

He is a farmer while his wife owns a grocery shop. Does not smoke but occasionally takes alcohol.His hobbies include reading, listening to music and tending the flowers.O/E: Stable general outlook. Not sick-looking. NAD on examination of the head, Neck, back, chest. Hands.Left foot: The ankle joint is swollen. The patient reports painful joint and cannot walk well.ROM: ROM: Active: Flexion- Cannot flex the ankle due to pain on anterior aspect Extension- full range; with minimal pain on movementAbduction- painful Adduction- painfulMedial Rotation- painful Passive: Flexion- full range; with pain on anterior aspect the ankleExtension- full range; painful Abduction- full range; painfulAdduction- full range; painfulMedial Rotation- painfulResistive: Flexion-with intense pain on anterior aspect of ankleExtension- painful Abduction- painfulAdduction- painful Medial Rotation- painfulImpression: Ankle sprain Plan: Analgesics Diclofenac %50mg PO given, Range of motion exerceise.

Treatment: Analgesics. Weekly visit for physiotherapy.Advised: Rest the foot for one work. Maintain active range of motion to ensure maintenance of functionality (Lippincot 2008, p. 20).To take precaution whilst working because the ankle healing may be affected by strenuous exercise take at least one week before going back to work if possible.AbbreviationsPC- Presenting ComplainHPC- History of Presenting ComplainKg- KilogramPMH- Past Medical HistorySH- Social HistoryO/E- On ExaminationNAD- No Abnormality DetectedROM:- Range of MotionReferencesAngus, D.C. & van der Poll, T., 2013. Severe Sepsis and Septic Shock.

New England Journal of Medicine, 369, pp.840–851. Available at: Benson, L.S. et al., 2006. Dog and cat bites to the hand: Treatment and cost assessment. Journal of Hand Surgery, 31, pp.468–473.Dawood, M. (2012) The Emergency Practitioner’s Handbook: for all front line health professionals. London: Radcliffe PublishersDavies , F. Bruce, C.E. and Taylor-Robinson, K.J. (2011) A Pratical Handbook: Emergency Care of Minor Trauma in Children. Uk: Hodder Arnold an Hachette Uk CompanyGreaves, I.

& Johnson, G. (2002) Practical Emergency Medicine. London: Arnold Publisher.Kaufman, J.L., 2008. Management of acute cutaneous wounds. The New England journal of medicine, 359, pp.2395–2396; author reply 2396.