PATIENT NAME:

Tamara Mallin.

PATIENT NUMBER:

Null, Not Assigned.

DATE OF EXAM:

11/11/2019.

REFERRING DOCTOR:

Patricia Allems, M.D

READON FOR VISIT:

Swelling in the left ankle, since 11/2/2019. Dr. Allems was unable to determine the causation.

CURRENT SYMPTOMS:

Unable to bear much weight on the left ankle. Chronic limp. Swelling is the same in size since 11/2, when first noticed by the patient.

EXAM OVERVIEW:

The patient, a 46 year old famale, presented today with a complaint of swelling in her left ankle. The patient does not recall any activity or event which precipated the swelling. She’s been doing some renovation of her home garden, but again she does not recall becoming injured during  this process. On 11/2, she woke in the morning, and noticed pain and swelling in her ankle when she moved to stand up. She stayed indoors on this day, to see if rest would improve it. When asked as to any self treatment, she stated that she took over-the-counter ibuprofen and also iced and elevated her ankle in the evening. She continued this regimen before calling her physician.

She stated that she waited three days before presenting to her general practitioner. She said that she thought the swelling would resolve itself, and when it didn’t, she made an appointment.

Dr. Allems conducted an overall evaluation of the ankle, and took a history from patient, but couldn’t determine what occurred to creat the swelling, and why such swelling has continued. For this reason, the patient was referred to me today for an opinion as to the swelling causation.

In further questioning of the patient, she noted that swelling has largely remained the same since she noticed it. It hasn’t improved, but it hasn’t gotten worse either. She’s not sure if her home treatment worked, although it may have in that the swelling did not continue to increase.

In examining the left ankle today, I noted significantly swelling, with purple bruising around the Achilles tendon. The ankle was somewhat painful to the touch, with the patient ratung it at 6 on the pain scale.  When I asked her to bear weight on the ankle, the patient could only momentarily. The patient states that she’s being using crutches to ambulate.

DIAGNOSIS:

There is no obvious sign of trauma outwardly to the ankle. The bruising seems to be a product of possible internal damage or bleeding around the Achilles tendon site.  At this time, my diagnosis would be internal trauma to the the left ankle, with additional testing required. I prove of the use of crutches at this time, as I feel that a CAM boot on this untreated ankle and tendon may cause further trauma. As further trauma could complicate a potential surgery, it is especially important that this be avoided if at all possible.

FURTHER ACTION:

I'm recommending that the patient umdergo an MRI of the left ankle, followed by a possible X-ray with contrast If the MRI does not provide more definitive results. As I explained it to the patient, it’s very possible that this injury will self resolve with rest and some medication. However, there is a possibility that surgery will be required. At this time, I believe that surgery would be a last option, but I didn’t want the patient to be completely unprepared if this must be considered.

MEDICATION:

I recommend continued over-the-counter ibuprofen at this time. No prescription was provided.

FOLLOW-UP VISIT:

Once the required testing has been completed, and the films reviewed, the patient should return for a follow-up visit so I can examinine the films and study the notes. At this time, I think a follow-up visit date in 6 to 8 weeks would be sufficient.