History of Present Problem: The patient is a 40-year-old Caucasian female who presents to clinic accompanied by her husband for evaluation and treatment of left ankle pain. The patient was involved in a motor vehicle accident at age 19 and sustained an open fracture and dislocation of left bi-malleolar ankle fracture as well as a torn right anterior cruciate (ACL). She underwent an open reduction internal fixation (ORIF) of the left ankle fracture emergently. After the left ankle healed, a right ACL reconstruction was completed. Both injuries healed without problems and she was pain free until two years ago when her left anterior ankle joint became painful with ambulation. The left ankle pain increases when she is walking barefoot and is alleviated
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Social History: The patient is married and has two female children, aged 19 and 17 years old. She has a high school diploma and works as a hospital registration clerk. The patient does not drink alcohol or use illicit drugs but she smokes 8-10 cigarettes daily. She is sexually active in a monogamous relationship with her husband.
Review of Systems:
General constitutional symptoms: Patient denies fever, chills, sweats, fatigue, unexplained weight change. The patient states she has good hydration and nutritional intake. Patient well kept, dressed well and appropriate mood.
Skin, Hair Nails: Patient denies rashes, jaundice, pruritus discharge, or any new skin abnormalities, bruising or bleeding.
Head: The patient denies headache or head pain and denies head or neck trauma, pain or limitation of range of motion to head or neck.
Eyes: Patient reports no visual disturbances. Patient denies eye pain, eye swelling, eye discharge, eye dryness or
Social History: The patient is married and has two female children, aged 19 and 17 years old. She has a high school diploma and works as a hospital registration clerk. The patient does not drink alcohol or use illicit drugs but she smokes 8-10 cigarettes daily. She is sexually active in a monogamous relationship with her husband.
Review of Systems:
General constitutional symptoms: Patient denies fever, chills, sweats, fatigue, unexplained weight change. The patient states she has good hydration and nutritional intake. Patient well kept, dressed well and appropriate mood.
Skin, Hair Nails: Patient denies rashes, jaundice, pruritus discharge, or any new skin abnormalities, bruising or bleeding.
Head: The patient denies headache or head pain and denies head or neck trauma, pain or limitation of range of motion to head or neck.
Eyes: Patient reports no visual disturbances. Patient denies eye pain, eye swelling, eye discharge, eye dryness or