Sample Name: Ankle Sprain - H&P
Description: History and Physical for right ankle sprain
(Medical Transcription Sample Report)
CHIEF COMPLAINT: Right ankle sprain.
HISTORY OF PRESENT ILLNESS: This is a 56-year-old female who fell on November 26, 2007 at 11:30 a.m. while at work. She did not recall the specifics of her injury but she thinks that her right foot inverted and subsequently noticed pain in the right ankle. She describes no other injury at this time.
PAST MEDICAL HISTORY: Hypertension and anxiety.
PAST SURGICAL HISTORY: None.
MEDICATIONS: She takes Lexapro and a blood pressure pill, but does not know anything more about the names and the doses.
SOCIAL HISTORY: The patient lives here locally. She does not report any significant alcohol or illicit drug use. She works full time.
FAMILY HISTORY: Noncontributory.
REVIEW OF SYSTEMS:
Pulm: No cough, No wheezing, No shortness of breath
CV: No chest pain or palpitations
GI: No abdominal pain. No nausea, vomiting, or diarrhea.
GENERAL APPEARANCE: No acute distress
VITAL SIGNS: Temperature 97.8, blood pressure 122/74, heart rate 76, respirations 24, weight 250 lbs, O2 sat 95% on R.A.
NECK: Supple. No lymphadenopathy. No thyromegaly.
CHEST: Clear to auscultation bilaterally.
HEART: Regular rate and rhythm. No murmurs.
ABDOMEN: Non-distended, nontender, normal active bowel sounds.
EXTREMITIES: No Clubbing, No Cyanosis, No edema.
MUSCULOSKELETAL: The spine is straight and there is no significant muscle spasm or tenderness there. Both knees appear to be non-traumatic with no deformity or significant tenderness. The right ankle has some swelling just below the right lateral malleolus and the dorsum of the foot is tender. There is decreased range of motion and some mild ecchymosis noted around the ankle.
DIAGNOSTIC DATA: X-ray of the right ankle reveals no acute fracture by my observation. Radiologic interpretation is pending.
IMPRESSION: Right ankle sprain.
1. Motrin 800 mg t.i.d.
2. Tylenol 1 gm q.i.d. as needed.
3. Walking cast is prescribed.
4. I told the patient to call back if any problems. The next morning she called back complaining of worsening pain and I called in some Vicodin ES 1-2 p.o. q. 8 hours p.r.n. pain #60 with no refills.
Keywords: orthopedic, ankle sprain, foot inverted, injury, x-ray, walking cast, ankle, sprain,