Right Lateral Ankle Sprain and Dysuria

Case introduction

A 19-year-old athletic male, Chris Martinez, visits a family medicine clinic with complaints of right ankle pain due to an inversion sprain in a soccer match. The patient has been able to walk off the field after sustaining the injury, but on the following day, he complained of pain along the lateral side of his ankle with slight swelling. This pain has limited them from walking on their own. Although their mother wanted to have an x-ray to exclude fracture, clinical examination combined with the Ottawa ankle rules eliminates the need for imaging. At the same time, the patient reports dysuria; therefore, further assessment is required to treat both issues.

Main Diagnosis and Rationale

The primary diagnosis for Chris is the right lateral ankle sprain. This diagnosis is further affirmed by the mechanism of injury and physical assessment revealing point tenderness over the lateral ligaments and mild swelling without deformation, suggesting a grade I or II sprain. The Ottawa ankle rules, which assist in ruling out fractures in cases of ankle injuries, do not call for an X-ray, which supports the conclusion of a sprain over a fracture (Gomes et al., 2022). The findings of the inversion injury that resulted in lateral ligament strain are consistent with a sprain, given that there is no bone tenderness and the patient was able to bear weight after the injury.

Differential Diagnoses

Fracture

A fracture was initially suspected based on the mechanism of injury and the inability of the patient to comfortably bear weight. However, lack of bone tenderness and negative Ottawa ankle rule, which is sensitive in ruling out fractures, ruled out this differential (Gomes et al., 2022).

Peroneal Tendon Injury

Likewise, peroneal tendon injuries were considered because they are often related to inversion injuries, as indicated by Danna and Brodsky (2020). However, since there were no symptoms like popping sensations, instability, and persistent pain, particularly over the tendons, coupled with a negative tendon test, the diagnosis was ruled out.

Diagnostic Plan

The diagnostic plan is mostly restricted to the general clinical examination that is supported by selective imaging if future symptoms or lack of progress are observed. About the current presentation and compliance with clinical protocols, there is no need for urgent imaging. Rather, it lies in clinical reevaluation and tracking of changes in symptoms and their manifestations. Thus, when there is a suspicion of accompanying conditions, as is dysuria in this case, urinalysis and urine culture tests are ordered to rule out a urinary tract infection (UTI) (Sabih & Leslie, 2023).

Treatment Plan

Right Lateral Ankle Sprain

The treatment plan for Chris’s right lateral ankle sprain involves the RICE protocol: This is an acronym that stands for Rest, Ice, Compression, and Elevation. Avoiding putting weight on the injured ankle to minimize stress, putting ice on the swollen area to help minimize swelling, wrapping the injured area with an elastic bandage to provide support and help reduce swelling, and raising the ankle above heart level to help decrease swelling are the first recommended steps. Analgesics like ibuprofen, which belongs to the category of nonsteroidal anti-inflammatory drugs (NSAIDs), may be administered in cases of pain and inflammation. The patient should be made to understand the need to stick to the RICE protocol and look for other complications, such as increased pain or swelling and the slow process of healing.

Dysuria and Suspected UTI

About the dysuria, based on the patient’s symptoms and history, a tentative diagnosis of a urinary tract infection was made. Trimethoprim-sulfamethoxazole should be used while waiting for the results of urine culture (Leung et al., 2019). He should be educated on the symptoms of a UTI, the importance of taking all prescribed antibiotics, and the need to drink water regularly. Moreover, the arrangement of a review within 1 week assists in managing the further treatment of the ankle injury and the results of the UTI, whether the patient’s condition improves or worsens.

Patient Education

Patient education is also crucial in increasing patients’ compliance with medications and other treatments, as stated by Bhattad and Pacifico (2022). Some specific things that Chris should be aware of are the RICE regimen for the ankle sprain, indications of complications, and some activities to avoid. Regarding the UTI, Chris has to take all the antibiotics prescribed by the doctor and drink as much water as possible while avoiding anything that may irritate them. They should also be educated on signs of worse conditions, such as severe pain and high fever, and the necessity of review appointments to assess the results of the change in management.

Follow-Up Care

The follow-up is vital to ensure that the client is cleared of the symptoms and to address any emergent adverse effects (Taberna, 2020). About the ankle sprain, Chris should be reviewed after a prescribed period to assess progress and modify treatment appropriately. In case of persistent or increased severity, additional diagnostic procedures, possibly including imaging, may be needed. Follow-up for the UTI: Make sure that the infection is cleared with the antibiotic treatment given and make necessary changes if it does not improve. This thorough subsequent care ensures a good recovery and also fixes any complications that may arise as they are noticed.

References

Bhattad, P. B., & Pacifico, L. (2022). Empowering patients: Promoting Patient Education and Health Literacy. Cureus, 14(7). https://doi.org/10.7759/cureus.27336

Danna, N. R., & Brodsky, J. W. (2020). Diagnosis and Operative Treatment of Peroneal Tendon Tears. Foot & Ankle Orthopaedics, 5(2), 247301142091040. https://doi.org/10.1177/2473011420910407

Gomes, Y. E., Chau, M., Banwell, H. A., & Causby, R. S. (2022). Diagnostic accuracy of the Ottawa ankle rule to exclude fractures in acute ankle injuries in adults: a systematic review and meta-analysis. BMC Musculoskeletal Disorders, 23(1). https://doi.org/10.1186/s12891-022-05831-7

Leung, A. K. C., Wong, A. H. C., Leung, A. A. M., & Hon, K. L. (2019). Urinary Tract Infection in Children. Recent Patents on Inflammation & Allergy Drug Discovery, 13(1), 2–18. https://doi.org/10.2174/1872213X13666181228154940

Sabih, A., & Leslie, S. W. (2023, November 12). Complicated urinary tract infections. National Library of Medicine; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK436013/

Taberna, M. (2020). The Multidisciplinary Team (MDT) Approach and Quality of Care. Frontiers in Oncology, 10(85), 1–16. PubMed. https://doi.org/10.3389/fonc.2020.00085

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• Brief introduction of the case

Right Lateral Ankle Sprain and Dysuria

• Identification of the main diagnosis with supporting rationale
• Identification of at least two additional differential diagnoses with a brief rationale for why these were ruled out
• Diagnostic plan with supporting rationale or references
• A specific treatment plan supported by recent clinical guidelines
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Summary:

Synopsis
Family Medicine 04: 19-year-old with sports injury

Chris Martinez is a 19-year-old patient with no significant past medical history who presents to an ambulatory family medicine office with a concern of right ankle pain after an inversion injury yesterday at a soccer game. They were able to walk off the field, but today, they note pain along the lateral aspect of the ankle, as well as slight swelling, and decline to walk without assistance. Their mother insists on an x-ray to rule out a fracture, but history, physical, and Ottawa ankle rules do not indicate a need for x-rays. The student learns how to deal with a patient or parent/caregiver demanding expensive tests that are not indicated. Chris is counseled regarding the treatment of their sprained ankle; they mention they have also been experiencing dysuria. Based on their history, a presumptive diagnosis of urinary tract infection is made. Appropriate treatment is discussed, and plans are made for a follow-up appointment.

PLEASE CHOOSE ONLY TWO DIFFERENTIALS:

There are two final diagnoses. Please explain why in the first paragraph
Final diagnoses: Right lateral ankle sprain, dysuria