Client presents to the urgent care center and reports injuring left ankle while playing basketball 2 days ago. Chief complaint: Pain in left ankle for 2 days’ duration.
Deep purple ecchymosis (bruising) 7 cm in diameter and 1+ edema noted along the outer aspect of the left ankle. Capillary refill on lower extremities is <2 seconds bilaterally, and skin is intact, warm, and dry. Pedal pulses are 2+ bilaterally. Client reports sharp pain in the left ankle and foot whenever moving foot or trying to walk. Client demonstrates guarded movements of left ankle and is hesitant to put weight on the left foot. Tenderness of ankle upon palpation noted. Client rates ankle pain a 7 on 0-to-10 pain scale. Client states no significant past medical history, states no history of surgeries, and does not take any routine medications. Client states ibuprofen 400 mg was taken every 8 hours since the time of injury, and pain was reduced to 5 on a 0- to-10 pain scale when taking the ibuprofen. Client has no known drug allergies.