WHITE MEMORIAL MEDICAL Los Angeles 1720 CESAR E.

CHAVEZ AVENUE

CONSULT - HISTORY AND PHYSICAL EXAMINATION

Presentation Date: 21.08.2017
Patient Name: XXXXXX XXXX
CHIEF COMPLAINT: Foot pain.

HISTORY OF PRESENT ILLNESS: This is a 17-year-old high school athlete

who swims for the swimming team. He was playing water polo with some
of his teammates when he dropped a weight on the dorsal aspects of his
feet. He was barefoot at that time. He had been in the pool practicing an
hour prior to this injury. Because of the contusions and abrasions to his
feet, his athletic trainer brought in him to the urgent care. He is able to bear
weight; however, complains of pain in his toes. The patient did have some
avulsion of the skin across the second and third toes of the left foot with
contusions across the second, third, and fourth toes and dorsum of the
foot.

PAST MEDICAL HISTORY: Significant for attention deficit hyperactivity disorder.

PAST SURGICAL HISTORY: Positive for wisdom tooth extraction.

Family history: Noncontributory.

Social History: He does not use alcohol, tobacco or

illicit drugs. He plays water polo for the school team.
Immunization history: All immunizations are up-to-date for age.
REVIEW OF SYSTEMS: The pertinent review of systems is as noted above; the remaining review of systems
was reviewed and is noted to be negative.

PRESENT MEDICATIONS: Provigil, Accutane and Rozerem.

PHYSICAL EXAMINATION:
GENERAL:
ALLERGIES: This is a pleasant white male in no acute distress.
None.
VITAL SIGNS: He is afebrile. Vitals are stable and within normal limits.
HEENT: Negative for acute evidence of trauma, injury or infection.
LUNGS: Clear.
HEART: Regular rate and rhythm with S1 and S2.
ABDOMEN: Soft.
EXTREMITIES: There are some abrasions across the dorsum of the right foot including the second, third and
fourth toes. There is some mild tenderness to palpation. However, there are no clinical fractures. Distal pulses
are intact.
BACK EXAM: Nontender.
NEUROLOGIC EXAM: He is alert, awake and appropriate without deficit.

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WHITE MEMORIAL MEDICAL Los Angeles 1720 CESAR E. CHAVEZ AVENUE

RADIOLOGY: AP, lateral, and oblique views of the feet were conducted per Radiology, which were

negative for acute fractures and significant soft tissue swelling or bony injuries. On reevaluation, the patient was

resting comfortably. He was informed of the x-ray findings. The patient was discharged in the care of his mother

with a preliminary diagnosis of bilateral foot contusions with superficial avulsion lacerations, not requiring

surgical repair.

DISCHARGE MEDICATIONS: Darvocet.

The patient’s condition at discharge was stable. All medications, discharge instructions and follow-up
appointments were reviewed with the patient/family prior to discharge. The patient/family understood the
instructions and was discharged without further incident.

DISCHARGE INSTRUCTIONS:

Medicines:

Self-care:
 Antibiotics: This medicine is given to help treat or prevent an infection caused by bacteria.
Follow-up:
 NSAIDs: These medicines decrease swelling and pain. NSAIDs are available without a doctor's order. Ask
which medicine is right for you. Ask how much to take and when to take it. Take as directed. NSAIDs can
Follow-up care is a key part of your treatment and safety. Be sure to make and go to all
cause stomach bleeding and kidney problems if not taken correctly.
appointments, and call your doctor or nurse call line if you are having problems. It's also a
 Pain medicine: You may be given a prescription medicine to decrease pain. Do not wait until the pain is
good idea to know your test results and keep a list of the medicines you take. Watch closely
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Rest: You may need to rest your foot and Elevate your foot: Raise your foot at or above
avoid activities that cause pain. For stress the level of your heart as often as you can.
fractures, you will need to avoid the activity This will help decrease swelling and pain. Prop
that caused the fracture until it heals. your foot on pillows or blankets to keep it
elevated comfortably.
Ice: Ice helps decrease swelling and pain. Ice
may also help prevent tissue damage. Use an Physical therapy: Once your foot has healed, a
ice pack or put crushed ice in a plastic bag. physical therapist can teach you exercises to
Cover it with a towel, and place it on your foot help improve movement and strength, and to
for 15 to 20 minutes every hour. decrease pain.

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WHITE MEMORIAL MEDICAL Los Angeles 1720 CESAR E. CHAVEZ AVENUE

CARE FOR YOUR FOOT:

Follow your treatment plan to help Compression: Compression (tight hold)

decrease your pain and improve your provides support and helps decrease
muscle movement. swelling and movement so your foot can
Rest: You will need to rest your foot for 1 heal. You may be told to keep your foot
to 2 days after your injury. This will help wrapped with a tight elastic bandage.
decrease the risk of more damage. Follow instructions about how to apply
Ice: Ice helps decrease swelling and pain. your bandage. Do not massage your foot.
Ice may also help prevent tissue damage. You could cause more damage or pain.
Use an ice pack, or put crushed ice in a Elevation: Keep your foot raised above the
plastic bag. Cover it with a towel and level of your heart while you are sitting or
place it on your foot for 15 to 20 minutes lying down. This will help decrease or limit
every hour or as directed. swelling. Use pillows, blankets, or rolled
towels to elevate your foot comfortably.

Exercise your foot:

You may be given gentle exercises to improve your foot movement and help
decrease stiffness. Ask when you can return to your normal activities or
sports.

Prevent
another injury:

Wear equipment to protect yourself when you play

sports.
Make sure your shoes fit properly.
Always wear shoes on streets or sidewalks.
Clean spills off the floor right away to
avoid slipping or
hitting your foot.
Make sure your home is well lit when
you get up during

the night. This will help you avoid hurting your foot
in
the dark.

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