i-human-case-
study-14-year-old-
with-pain-and-
swelling-in-right-
ankle-latest-august-
2024-
comprehensive-
case-study
,
,Patient Name: Andrew Chen
💬 Chief Complaint
"I hurt my ankle playing basketball and I can't walk on it."
📝 Triage Note / Initial Presentation
Andrew Chen is a 14-year-old male who presents to the clinic accompanied by his
mother. He reports sustaining an injury to his right ankle approximately two hours ago
while playing basketball at school. He states that he tripped over another player's foot
while attempting a shot and fell, with other players landing on his leg. Since the injury,
he has been unable to bear weight on the affected ankle. He has tried icing, elevating,
and taking ibuprofen at home without significant relief. He rates his current pain as
10/10 and describes it as throbbing. The swelling and bruising have been progressively
worsening since the injury occurred.
📊 Vital Signs (Initial)
Measurement Value
Blood Pressure 101/78 mmHg
Heart Rate 92 bpm
Respiratory Rate 21 breaths/min
Temperature 98.7°F (37.1°C)
, Measurement Value
Oxygen Saturation 98% on room air
BMI 24.1 kg/m² (85th percentile)
⚡ Onset & Context
Onset: Acute, sudden
Duration: ~2 hours
Context: Occurred during a basketball game at school
Mechanism: Twisting injury with axial loading (tripped + fell + other players
landed on ankle)
Course since onset: Progressive worsening of pain, swelling, and bruising
🏥 Setting
Type of Encounter: Acute care visit (Emergency Department/Urgent Care)
Arrival: Ambulatory with assistance (crutches not yet provided)
Accompanied by: Mother
Patient Information
study-14-year-old-
with-pain-and-
swelling-in-right-
ankle-latest-august-
2024-
comprehensive-
case-study
,
,Patient Name: Andrew Chen
💬 Chief Complaint
"I hurt my ankle playing basketball and I can't walk on it."
📝 Triage Note / Initial Presentation
Andrew Chen is a 14-year-old male who presents to the clinic accompanied by his
mother. He reports sustaining an injury to his right ankle approximately two hours ago
while playing basketball at school. He states that he tripped over another player's foot
while attempting a shot and fell, with other players landing on his leg. Since the injury,
he has been unable to bear weight on the affected ankle. He has tried icing, elevating,
and taking ibuprofen at home without significant relief. He rates his current pain as
10/10 and describes it as throbbing. The swelling and bruising have been progressively
worsening since the injury occurred.
📊 Vital Signs (Initial)
Measurement Value
Blood Pressure 101/78 mmHg
Heart Rate 92 bpm
Respiratory Rate 21 breaths/min
Temperature 98.7°F (37.1°C)
, Measurement Value
Oxygen Saturation 98% on room air
BMI 24.1 kg/m² (85th percentile)
⚡ Onset & Context
Onset: Acute, sudden
Duration: ~2 hours
Context: Occurred during a basketball game at school
Mechanism: Twisting injury with axial loading (tripped + fell + other players
landed on ankle)
Course since onset: Progressive worsening of pain, swelling, and bruising
🏥 Setting
Type of Encounter: Acute care visit (Emergency Department/Urgent Care)
Arrival: Ambulatory with assistance (crutches not yet provided)
Accompanied by: Mother
Patient Information
