A Case Study Of John Shelter's Collapse

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CHIEF COMPLAINT: Right ankle pain.

HISTORY OF PRESENT ILLNESS: John Walters is a 59-year-old male who injured his right lower extremity in a fall on October 8, 2015. He was seen in the emergency department where he was clinical and radiographic evaluated. There was felt to be a small avulsion fracture of the talus. He was placed into a splint and asked to be nonweightbearing and referred to this office for definitive evaluation and treatment. He currently states that he has pain in and around the posterior and lateral ankle. This is worse with motion and activity. He and his wife state that the main problem that led to the fall was numbness and pain along the lateral thigh on the right. This has been more chronic in nature. He has
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He is examined while seated on examination table. His splint has been removed from the right lower extremity. He is utilizing crutches for assistance in walking and was nonweightbearing. The cervical, thoracic, and lumbar spine is nontender to palpation. His shoulders, elbows, wrist, and hands move through a full range of motion without limitation or pain generation. He is nontender to the upper extremities, axillary, radial, median, and ulnar nerves are intact to motor and sensory tone bilaterally. There are not skin lesions or vascular compromise. Pelvis is stable. Left lower extremity shows full range of motion at the hip, knee ankle, and foot without tenderness to palpation, neurologic compromise, or gross vascular restriction. There is no tenderness to palpation. Examination of the right lower extremity shows the patient has tenderness to palpation along the lateral thigh, especially at the mid portion of the right trochanter. Ober 's test is not performed at this time given the patient 's posturing, but he shows gross clinical symptoms of inflamed bursa through the right trochanteric region. Knee motion is full and shows no limitations. The ankle is mildly swollen. He is tender to palpation diffusely along the lateral and posterior lateral aspects of the ankle. No deltoid tenderness is noted. He has a negative Drawer 's test of the ankle. Motion is …show more content…
We have recommended physical therapy for the alleviation of symptoms. This was met with a negative response by the patient significant other and that it has not worked. It sounds like it was given minimal follow up or effort and this is again encouraged. For the acute process foot fracture, we have placed him in a CAM walker boot. It is okay to be weightbearing as long as the boot is present. He can move it through a range of motion without the boot as long as he is nonweightbearing. We will see him in two weeks ' time for repeat clinical and radiographic evaluations. He should consistent with RICE type therapies for symptom alleviation until such time he is seen again. He was asked to contact us immediately if there is any other change in his

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