Acute ankle sprain

This is an 18-year-old male patient, who presents to the pain clinic today complaining of pain in his right ankle. He was playing soccer on 04/15/12 and hyperextended his right ankle with extreme plantar flexion. He was running after a soccer ball and came down his ankle in this manner. Initially, he was unable to bear weight and there was some severe pain. He was taken to emergency room at Raritan Bay Hospital and had x-rays initially, which he was told did not reveal any fracture. He was given naproxen and told to take Aleve at home. At this point, the pain is intermittently rated as 8/10 on a visual analog scale. He has severe pain with weightbearing. He has complaints of severe swelling and numbness feeling in the extremity. Pain is dull and achy in nature. He has had no alleviating factors other than elevation of the leg. He has had no treatment for the pain otherwise.

DIAGNOSES:
Acute ankle sprain.
Ankle joint pain.

RECOMMENDATIONS:
We will recommend an Aircast for the patient’s ankle and no weightbearing for the next week. I have recommended use of crutches. I have ordered naproxen 500 mg one q.12h. for pain and inflammation and Vicodin ES one every four to six hours as needed for severe pain, #20 dispensed with no refills. We will start physical therapy and see him back in a week. He has major sports event in two weeks and I am not sure that he has been able to perform given his current injury though we will reevaluate him in one week.

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