HPI:
There is pain in the ankle which has progressed to the point that it limits activity and sleep. It is affecting daily activities. There has not been improvement with conservative care.
Diagnostic Studies:
Xray series of the ankle including A/P, mortise and lateral views taken in the office today was personally evaluated by me and demonstrates the following: Fracture (s) and/or Dislocation(s): None . Alignment: Normal . Joint space(s): Normal . Soft tissues: Normal .
Physical Exam:
General Appearance: Well-nourished, well developed in no acute distress. Orientation: Oriented to person, place and time. Mood / Affect: Calm. Gait: antalgic Coordination: normal. Ankle / foot Exam (Bilateral): Inspection / Palpation LE (R/L): nontender. Dorsiflexion (R/L): 25º / 25º. Plantarflexion (R/L): 50º / 50º. Strength LE: 5/5 EHL, tibialis anterior, plantar flexion bilaterally. Sensation: subjective normal distal sensation bilateral LE. Vasculature: <2 second distal capillary refill bilaterally. LE Skin: No rashes, no lesions. Skin and lymph: appears normal in the affected extremity.
Assessment:
Contusion of right ankle
Plan:
Discussed natural history, operative and non-operative treatments; risks, benefits and expected rehab course of each. All questions were answered.
Category:
- Injury
ICD-10:
S90.01XA
ICD:
S90
Encounter:
- Initial
ICD-10CM Year:
2019