ANKLE T-SHEET
CC:
Ankle Pain R 
HPI:
Onset:
Mechanism of injury:
Location:
Radiation:
Yes 
Exacerbating factors:
Relieving factors:
L 
Both 
No 
Where:
ROS:
Fever  Chills 
Numbness  Paresthesias 
Weakness  Night Pain 
Weight Loss 
Amount_________
Pain at Rest 
Swelling after Activity  _____________________
PMHx:
Meds:
Allergies:
Chronic medical conditions:
Immunizations Current:
Yes  No 
Soc Hx:
Occupation and/or Activities:
Smoking status: Current  Past  Never 
IV Drug Use:
Yes  No 
PE:
Vital Signs:
BP:
P:
Wt:
BMI:
RR:
General Appearance:
Gait:
Normal 
Limp 
Skin:
Redness
Yes 
Warmth
Yes 
Ecchymosis Yes 
Deformity
Yes 
Ulcers
Yes 
Distal Hair pattern:
Assist  _________________ Unable to bear weight 
No 
No 
No 
No 
No 
Vascular:
Dorsalis Pedis Pulse:
Post Tibialis Pulse:
Capillary Refill:
Neuro:
Toe Raise (peroneal):
Distal Sensation:
ROM:
Dorsiflexion:
Plantar Flexion:
1st MP Joint:
Anterior Drawer Sign
Active Eval:
(Neutral):
Anterior Drawer Sign (Plantar):
Thompson (Squeeze):
Ottawa
Rules:
Navicular tender:
Medial Malleolus tender:
Lateral Malleolus tender:
Base of 5th metatarsal tender:
Location:
Location:
Location:
Location:
Location:
Normal 
Decreased 
Right
Left
Nl    Absent 
Nl    Absent 
Normal  Slow 
Nl  Abnormal 
Nl  Abnormal 
Nl    Painful 
Nl    Painful 
Nl    Painful 
Nl    Absent 
Nl    Absent 
Normal  Slow 
Nl  Abnormal 
Nl  Abnormal 
Nl    Painful 
Nl    Painful 
Nl    Painful 
Nl  Abnormal 
Nl  Abnormal 
Nl  Abnormal 
Nl  Abnormal 
Nl  Abnormal 
Nl  Abnormal 
Yes 
Yes 
Yes 
Yes 
No 
No 
No 
No 
Yes 
Yes 
Yes 
Yes 
No 
No 
No 
No 
TREAT APPROPRIATELY
TREAT WITH CLOSE
FOLLOW-UP
Ankle/Foot Pain........... 719.47
Achilles tendonitis ....... 726.71
Ankle Sprain ................ 845.00
Tendonitis ................... 726.79
Foot Sprain/Strain ....... 845.10
Unable to bear weight with negative X-ray findings
Cellulitis of Foot/Ankle
(< 1 week f/u)
CALL CONSULTANT
THAT DAY
CONSULT
OR
REFER
Uncertain X-ray findings
Fracture
Cold/Avascular Foot
Diagnosis uncertain/perplexing
Septic joint
Nerve entrapment
Fractures, if not comfortable treating
Torn Achilles
Vascular disease needing surgical treatment
Plan:
 Xray / Imaging
 Laboratory Eval
 NSAIDs
 Acetaminophen
 Other
 PRICE Protocol
 Physical Therapy
Disposition:
 Treatment initiated: Follow-up __________ weeks
 Treatment / Work up Initiated: Follow-up ≤ 1 week __________ days
 Immediate call to Dr.
 Consultation initiated with Dr.
 Referral to Dr.