PATIENT DASHBOARD

PATIENT DASHBOARD

Patient Name: Chris Martinez

Age: 19

Sex assigned at birth: female

Gender identity: nonbinary

• Pronouns: they/them/theirs

Language for medical communication: English

• You are working with Dr. Nayar this morning, and notice a patient limping down the hallway toward the examination rooms, helped by a medical assistant. The patient is accompanied by what looks like a family member. Several minutes later, the nurse confirms that this is your next patient, accompanied by their mother.

You review the electronic health record (EHR) with Dr. Nayar and consider which aspects of the past medical history you will want to obtain from Chris. The EHR includes their gender identity and pronouns, including the name Chris, different from the legal name, pronouns they/them, and nonbinary gender identity.

• Chief concern: 19-year-old presenting with right ankle pain.

Problem list:

• Otitis media (age 2)

Mononucleosis (age 14)

• You go to the exam room and introduce yourself and your pronouns to the patient, Chris, and their mother, Mrs. Martinez. You ask what name and pronouns the patient uses, and they state they use Chris and they/them pronouns and have told their family and friends this. They ask their mother to stay in the room. You then talk to Chris about the mechanism and timing of their ankle injury.

“Can you tell me more about how you hurt your ankle?”

They elaborate, “I was playing soccer last night and was trying to pass the ball to a teammate. Somehow I slipped and fell.”

“Do you know which way you fell on your ankle?”

Chris says, “My ankle really hurts along the outside. I am having a lot of problems walking and it’s a little stiff. It was really swollen yesterday, but not as bad today.” 

Mrs. Martinez adds, “I saw their ankle twist inward as they fell to the ground. The coach immediately iced the area and they were able to leave the field under their own power.”

“Have you ever had other difficulties with your ankle?”

“No, this is the first time anything like this has ever happened.”

“Do you have other health concerns you would like to address today?”

• “Actually, I have been having problems when I pee, but I want to talk about my ankle first.”
• Given this information, you suspect Chris’s injury is significant and follow up by asking questions to eliminate the possibility of a limb-threatening injury.

When you ask Chris about the signs and symptoms that could indicate a limb-threatening injury, they answer that they have pain only at the ankle, but none of the other symptoms.

COMPLETING GENERAL HISTORY

You now turn to Chris’s past medical history and they tell you that their only significant past medical history includes: “Some problems with ear infections when I was younger. Around age 14 or 15 I got mono.” On further questioning you learn that Chris has never had any surgeries, they have no allergies, use no substances, and their family history is significant for heart disease.

You have obtained all of the historical information that you need at this point, and decide to do a physical exam. Your initial exam reveals the following:

Vital signs:

Temperature: 37.2 C (98.8 F)

Pulse: 87 beats/minute

Respiratory rate: 22 breaths/minute

Blood pressure: 126/74 mmHg

Cardiovascular: Regular rate and rhythm.

Respiratory: Normal breath sounds without wheezes.

SUMMARY STATEMENT

The patient is a 19-year-old who presents with acute onset right ankle pain after an inversion injury playing soccer. They could bear weight on the joint immediately after the injury but they cannot currently walk without assistance in the office. There is mild swelling, no tenderness to palpation of the medial malleolar area, no tenderness over the dorsal or lateral aspect of the foot, but tenderness is present over the lateral malleolus of the right foot.

The ideal summary statement concisely highlights the most pertinent features without omitting any significant points. The summary statement above includes:

Epidemiology and risk factors: 19-year-old 

Key clinical findings of the present illness using qualifying adjectives and qualifying adjectives and descriptive language. 

Acute onset following inversion injury

Initially weight-bearing, but not currently weight-bearing

• Mild swelling

No tenderness to palpation of the medial malleolar area

• No tenderness over the dorsal or lateral aspect of the foot

Tenderness is present over the lateral malleolus of the right footDIFFERENTIAL DIAGNOSIS

• B. Fibular fracture

C. Lateral ankle sprain

• After further consideration of your differential, you tell Dr. Nayar, “I think Chris has a lateral ankle sprain, although I’m not sure how severe it is.”

Dr. Nayar agrees, “That appears most likely given their age and the fact that it’s an acute injury. The mechanism of Chris’s injury gives us a good clue as to what most likely happened to them.”

REVIEWING THE ANKLE EXAM

You and Dr. Nayar concur that (if his exam findings are comparable to yours) Chris does not need radiographs of their ankle or foot.

“Now, let’s go talk with the family and see what we can do,” he suggests. Dr. Nayar enters the room with you and greets Chris and their family.

He addresses Chris,

“I have heard about your ankle injury. What is your biggest concern today about your ankle?”

He says, “Well, let me reexamine your ankle and we will let you know what we recommend. 

Chris nods in assent.

Dr. Nayar addresses you as he examines Chris’s ankle. Chris has maximal pain distal to the lateral malleolus. They don’t have any pain along the posterior aspects of the medial or lateral malleoli which is reassuring. Their range of motion is mildly restricted and I appreciate no swelling at this time.”

He continues by testing range of motion with the talar tilt test, as well as the calf squeeze and tibiofibular compression tests.. None of these maneuvers are positive.

Dr. Nayar now tells Chris and their mother that he agrees with you that they have an ankle sprain. Before he can discuss a possible treatment plan, Mrs. Martinez says, “We really want an x-ray. I trust you, but I just want to make sure that their ankle isn’t broken.” Dr. Nayar calmly explains to the family how he has diagnosed an ankle sprain.

• MANAGEMENT OF ANKLE INJURY
• “Even though an x-ray is not indicated today, there are other things we can do for Chris,” Dr. Nayar informs the family. He tells them about RICE and pain control.
• Chris wants to know, “I can do what you told me about rest, ice, and elevation—but what do I do about compression?”
• TEACHING POINT
• Management of Ankle Sprain
• RICE – Recommended for most musculoskeletal injuries especially in the acute phase. It should be noted that early mobility is very important, regardless of method of treatment, as long as more severe injury is ruled out.

Rest

• Ice

Compression

• Elevation

RESUMING ACTIVITY AFTER ANKLE INJURY

After discussing the various types of ankle support, you tell Chris, “The office has something called an Aircast. This will really help your ankle feel better faster.”

Dr. Nayar addresses Chris, “I know your biggest concern is when you can return to soccer. For now we will need to keep you off the soccer field. If you try to return too early, you may cause further injury.” He gives them a prescription for daily ankle exercises and makes a plan to re-evaluate in one week. He also noted that physical therapy is often very useful if the ankle does not heal quickly. 

CARING FOR ADDITIONAL PROBLEMS: DYSURIA

“So, I want to see you back here in one week,” Dr. Nayar concludes. “Before I let the medical student finish up with you, are you sure that we don’t need to speak about your problems with urination?”

Chris says, “Well, I really don’t know if it’s that big of a deal.”

“OK,” says Dr. Nayar. “I think that it’s important to follow up on this. I am going to have our student ask you a few more questions to get a better handle on things after we get the ankle support for you.”

While you are both in the supply room finding an ankle support, Dr. Nayar points out, “Well, this is a perfect illustration that patients may have other issues that may not come completely to the surface unless you ask them directly. Sometimes, the patient may have other issues, and if we appear hurried, or not responsive, they will not ask. They may then leave unsatisfied. It is very important early in the visit to elicit and prioritize the patient’s concerns. That does not mean that you can address all of them. It may be necessary to bring the patient back for return visits until their needs have been adequately met.”

DIAGNOSING DYSURIA

The next step you would like to take to work up Chris’s symptoms is to see if you can elicit any costovertebral angle (CVA) tenderness and examine their abdomen. You tap Chris’s back below the ribs on both sides and elicit no expression of tenderness. They do not have suprapubic tenderness, rebound, or guarding.

TESTING FOR DYSURIA

After you respond to Chris’s question, you ask if they are ok with their mom coming back to the room (they agree) and have Chris go to the bathroom to leave a clean catch mid-stream urine sample. You excuse yourself to confer with Dr. Nayar. When you find Dr. Nayar in the hallway, you inform him of Chris’s urinary concern, adding that they didn’t have any evidence of an upper urinary tract infection but did have dysuria and frequency. 

Together, you review the results of Chris’s urinalysis:

Color: Pale yellow

pH: 5.0

Leukocyte esterase: +1

Glucose: Neg

Ketones: Neg

Protein: Neg

Bilirubin: Neg

Urobilinogen: Neg

Blood: +1

Nitrites: Neg

Sp. Grav.: 1.01

DYSURIA MANAGEMENT

When you return to the exam room, Dr. Nayar sits down and explains, “Chris, I agree with my student that you have a urinary tract infection. We will give you a prescription for an antibiotic to take twice a day for three days. I don’t anticipate there being any problems at the pharmacy, but give me a call if the copay is too expensive and we can work something else out. We would also like to have you schedule a follow-up visit next week to see how your ankle is doing as well as make sure the burning is all cleared up. If the burning is not gone, then we will need to do a pelvic examination to look for other causes for your problem. Is there anything else that we can help you with today?”

Chris shakes their head: “No, I just hope I don’t need that exam your mentioned.”

Dr. Nayar concludes, “All right. We’ll see you next week.”

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