Present Illness Case Study

Decent Essays
HISTORY OF PRESENT ILLNESS: This patient is a [_:03___] 15-year-old male he for followup with his right ankle fracture. He had seen Todd Reilly, MD last week in initial consultation. He had a medial malleolus fracture, which is below the weightbearing surface of the ankle. Apparently, at that time, options including surgical and nonsurgical options were discussed with the patient and they chose nonsurgical options. He is here for followup x-ray of the ankle. Dad is here as well and he seems to be doing a good job staying nonweightbearing on it.

PHYSICAL EXAM: He is in a CAM Walker today. Calves were soft and he has no pain to them.

IMAGING: Repeat x-rays of the ankle do show a medial malleolus fracture just at the very tip

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