Sports Medicine Acute Injury Assessment Note

Acute Care Visit Template

Chief Complaint

Acute right ankle inversion injury and lateral abdominal wall strain during recreational soccer.

History of Present Illness

Marcus Vance is a 28-year-old male who presents because of right ankle pain and mild right lower quadrant abdominal wall soreness.

Onset: 14/05/2024 at 18:30 during a soccer match.

Duration: 18 hours.

Characteristics: Sharp lateral right ankle pain rated 6/10; dull aching right lateral abdominal wall discomfort rated 3/10 after twisting to kick.

Aggravating factors: Weight-bearing on the right foot, inversion, and trunk rotation.

Relieving factors: Rest, ice, elevation, and compression wrap.

Associated symptoms: Localized lateral ankle swelling and ecchymosis. Denies joint locking, paresthesias, nausea, vomiting, or hematochezia.

Current Medications: Ibuprofen (Advil®) 400 mg PO TID PRN, omeprazole (Prilosec®) 20 mg PO daily.

Past Medical History

Gastroesophageal reflux disease (GERD), previous right Grade I ankle sprain (2021).

Social History

Never smoker; social alcohol intake (2–3 beers/week). Works as a software engineer. Plays recreational soccer twice weekly.

Review of Systems

• Constitutional: Denies fever, chills, or fatigue.
• HEENT: Denies headache or visual changes.
• Cardiovascular: Denies chest pain or palpitations.
• Respiratory: Denies SOB or cough.
• Gastrointestinal: Mild right oblique muscle soreness; denies deeper abdominal pain, nausea, vomiting, diarrhea, or melena.
• Genitourinary: Denies dysuria, frequency, or hematuria.
• Musculoskeletal: Positive for right lateral ankle pain, swelling, and stiffness; positive for right external oblique soreness.
• Skin: Ecchymosis over right lateral malleolus; no abrasions or lacerations.
• Neurological: Denies dizziness, numbness, tingling, or focal weakness.
• Psychiatric: Denies anxiety or depression.

Physical Examination

Vitals:

• Temperature: 36.8 °C
• Blood Pressure: 122/78 mmHg
• Heart Rate: 68 bpm
• Respiratory Rate: 14 breaths/min
• Oxygen Saturation: 99 % on room air

General: Alert, oriented, in mild distress when ambulating; antalgic gait.

• HEENT: Normocephalic, atraumatic, PERRLA.
• Cardiovascular: RRR, no murmurs, dorsalis pedis and posterior tibial pulses 2+ bilaterally.
• Respiratory: Clear to auscultation bilaterally, normal effort.
• Abdominal: Soft, non-distended. Superficial tenderness over the right external oblique insertion; negative Carnett's sign for intra-abdominal source. No rebound or guarding.
• Musculoskeletal: Right ankle with moderate swelling and ecchymosis anteroinferior to the lateral malleolus. Tenderness over the anterior talofibular ligament (ATFL). Negative tenderness at the base of the 5th metatarsal, navicular, or proximal fibula. Mild laxity on anterior drawer test; talar tilt test limited by pain. Active ROM decreased in plantarflexion and inversion.
• Skin: Intact, warm, dry, ecchymosis over right lateral ankle.
• Neurological: Sensation intact to light touch across L4–S1 dermatomes; 5/5 strength in dorsiflexion and eversion (pain-limited).

Assessment

Grade II right anterior talofibular ligament (ATFL) sprain and mild right external oblique muscle strain.

Rule out occult avulsion fracture of the lateral malleolus; NSAID-induced gastritis risk given history of GERD.

Plan

1. Diagnostic Studies: Right ankle 3-view radiographs ordered to exclude fracture (borderline Ottawa Ankle Rules tenderness).
2. Treatment: Apply semi-rigid ankle stirrup brace (Aircast®). Discontinue oral ibuprofen due to GERD history; switch to paracetamol (acetaminophen, Tylenol®) 1,000 mg PO TID PRN pain and diclofenac sodium (Voltaren®) 1 % topical gel 4 g applied to right ankle QID. Continue omeprazole 20 mg PO daily.
3. Patient Education: Advised on PRICE protocol (Protection, Rest, Ice, Compression, Elevation) for the first 48–72 hours. Weight-bearing as tolerated in brace. Avoid trunk twisting and soccer for 2–3 weeks.
4. Follow-up: Review in sports medicine clinic in 10 days for reassessment and physical therapy referral for proprioceptive rehabilitation.
5. Return precautions: Return immediately for inability to bear weight, numbness/tingling or coldness in toes, worsening abdominal pain, fever, or GI bleeding/melena.

X-ray reviewed prior to discharge: No acute fracture or dislocation identified; soft tissue swelling noted over lateral malleolus. Patient discharged home in stable condition at 11:45.