Ankle injury

{Ankle injury}

[+] yes, present, positive
[-] no, absent, negative
[~] equivocal
[\] not applicable, not performed
[?] unknown, unsure, unavailable
{ } annotation, comment

PRESENTING COMPLAINTS OR ISSUES
Injury details:
  Date and time of injury: 
  Injured side (L/R):

Mechanism / mechanics: 
[-] inversion
[-] eversion
[-] plantar flexion
[-] dorsiflexion
[-] twisting
[-] uncertain

Symptoms: 
[-] swelling
[-] bruising
[-] inability to bear weight^
[-] instability

PAST MEDICAL HISTORY
[-] significant ankle/foot injury: 
[-] congenital abnormality:

PHYSICAL EXAMINATION
[-] swelling 
[-] bruising 
  tenderness:
  [-] posterior edge or tip lateral malleolus^ 
  [-] posterior edge or tip medial malleolus^ 
  [-] base of the fifth metatarsal^ 
  [-] navicular bone^ 
  [-] mid-foot zone^ 
  [-] anterior talofibular ligament (ATFL) 
  [-] calcaneofibular ligament (CFL) 
  [-] posterior talofibular ligament (PTFL) 
  [-] Achilles tendon
  [-] distal tibia 
  [-] distal fibula 
  instability signs:
  [-] prone calf squeeze test for achilles tendon rupture 
  [-] anterior drawer test (integrity of ATFL, CFL and PTFL) 
  [-] talar tilt test (ATFL tear) 
  syndesmotic injury signs:
  [-] seated calf squeeze test (high ankle sprain) 
  [-] external rotation stress test (syndesmotic injury)

ASSESSMENT
Clinical summary:
[+] 
[~] 
[-]

Diagnosis/es:
1. 
2.

Differential diagnosis:
-

MANAGEMENT PLAN
Procedures performed:
-

Diagnostic investigations requested:
[-] X-ray ankle (^ above -- Ottawa ankle rules - indications for X-ray)
[-] Ultrasound ankle 
[-] MRI ankle

Referrals:
-

Information and advice given:
- Rest, ice, compression, elevation.

Medication:
-

Medical devices:
[-] controlled ankle movement boot. 
[-] other treatment:

FOLLOW-UP
Outstanding issues:
-

Next appointment:
-

Ankle injury

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