Human Case History Of Present Illness - Ihumanandrew C

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Ihuman Case History Of Present Illness Put In Ihumanandrew Che Andrew Chen is a 14-year-old male patient who presents to the clinic with his father with complaints of pain, bruising, and swelling in his right ankle. He was playing in an intense basketball game last night when he drove for a layup, in turn, stepping on his opponent's foot and falling. When he tried to get up, he had a pile of people on top of him. He had his trainer look at his ankle and wrap it with an ACE wrap when it happened. He took the ACE wrap off last night in order to shower and forgot to put it back on. He did ice and elevate his leg when he laid down. He says the bruising and swelling have both increased since the initial injury. He is unable to bear weight at this time due to the pain. He states the pain feels like someone is stabbing him at times and rates it a 10/10 when he tries to move his foot. There are no associated signs as he only complains of the pain from the ankle injury. He took Ibuprofen last night with some relief and again this morning about an hour ago.

Dr. Jack HW Helper · Accepted Answer

Andrew Chen, a 14-year-old male, presented with a history indicative of a recent ankle injury sustained during an intense basketball game. The injury occurred when he was attempting a layup, during which he stepped on an opponent’s foot and subsequently fell, with a pile of players landing on him. The initial response included immediate assessment and application of an Ace wrap by his trainer, indicating an immediate suspicion of soft tissue injury or possibly a fracture. Subsequently, he removed the wrap to shower, which may have affected the initial management and possibly contributed to the progression of swelling and bruising. The patient reports increased swelling and bruising since the incident, which is typical of traumatic injuries involving bleeding into tissue or near fractures. He is unable to bear weight on the affected ankle, suggesting significant injury, possibly involving ligaments, tendons, or bones. The pain described as stabbing with a severity of 10/10 upon movement further indicates significant trauma involving nociceptive nerve fibers, consistent with severe sprains or fractures. He managed the symptoms initially by icing and elevating the leg, which are first-line interventions to minimize swelling and control pain. The fact that swelling and bruising have worsened despite these measures suggests a dynamic injury process, which may include ongoing bleeding or tissue damage. His use of ibuprofen, a nonsteroidal anti-inflammatory drug (NSAID), provided some relief, supporting the presence of inflammation as part of his injury process. Given the mechanism of injury and clinical presentation, possible diagnoses include ankle sprain, ligamentous injury, or fracture. The inability to bear weight and severe pain are concerning features that warrant further diagnostic imaging, such as radiographs or MRI, to ascertain the extent of injury. Management should include rest, ice, compression, and elevation (RICE protocol), along with analgesics and further

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