Patient Name Francisco Explained for Students (Easy Guide)

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Original Question

Patient Name: Francisco Lopez Dx: Recurrent right ankle sprain Physician’s order: Evaluate and treat S: Patient is a 32 y.o. male, who injured his right ankle playing indoor soccer 3 weeks ago. Francisco works in the accounting department of a local hospital. Patient has sprained his ankle many times in the past, but the condition has always resolved itself over time. On this occasion, Francisco treated his ankle at home with ice right after the injury but has continued to attempt to participate in sports activities. He loves soccer, played in college, and would like to continue to play on a frequent recreational basis. He reports that the ankle continues to be swollen and painful along the lateral aspect, rating the pain at approximately 4/10. Patient reports he is generally healthy but lately his back is also bothering him and it is uncomfortable to lie on his stomach for extended periods. This has happened before, but usually resolves without treatment. O: General observation: The patient is a young, Latino male that ambulates independently into clinic with antalgic gait on the right Observation of area: The right lateral aspect of the ankle is edematous. There is slight residual ecchymosis noted. No differences in muscle bulk noted in calves bilaterally Posture: Patient stands with slightly ankles in slight pronation and pes planus bilaterally Palpation: There is tenderness upon palpation in the area of the anterior talof

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