Case Study: Pain Case

Case Study: Pain Case

History

TC is a 26-year-old runner who came into the office today complaining of constant pain in the right ankle. While running his usual route, he accidentally stepped on a branch lying in his path, twisting his ankle inward. He denies hearing a “pop.” He was able to walk, or limp, the remaining ¼ mile back to his home, where he immediately elevated and iced the ankle for 30 minutes. He took two acetaminophen 325mg, showered, dressed for work, and drove to his place of employment. He continued to experience significant pain in the ankle, worse when walking. He repeated the acetaminophen dose for 24 hours with no effect. His foot became swollen.

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Since his job in a sporting goods store requires that he be on his feet most of the day, he was unable to continue his normal workday and made a same-day appointment to be seen. He has no chronic diseases, takes no medication, and denies recent use of NSAIDs, as aspirin and ibuprofen have caused him to have gastritis in the past.  He did not remember what and how he took those medications specifically.  He sprained his ankle last year but was able to manage that injury at home.

Case Study: Pain Case

Assessment

A 26-year-old, otherwise healthy male presents limping into the examination room, holding his right shoe in his hand. He grimaces with partial weight-bearing of the affected foot. He has local ecchymosis and 1+ edema over the anterolateral ligaments of the right ankle. Capillary refill, pulses, and sensation of the foot and toes are intact. There is no lateral or anterior instability of the joint or tendons. X-ray of the ankle and foot are negative for fracture or dislocation. He has a grade I lateral ankle sprain.

What do you recommend for pain management for TC? Please be specific in medication, dosage, frequency, and duration. What counseling points do you give him, including specific counseling for the medication prescribed? Is any follow-up or monitoring needed?