[作業] Subjective

PT：薛＊傑

 Subjective:

 Name: 郭＊賓

Age: 23

Sex: male

Occupation: colleger

 Chief Complain發生經過:

Pain of medial Left ankle。Sudden onset.兩天前（2008.03.22） 的傍晚時分在夜市走路的時候，猛然不察突地被馬路上凹凸不平的坑洞拐到，事發當時左腳踝內側非常疼痛，但隱忍著卻還是可以走路（No stuck in position），硬撐著逛完夜市，再走回家，回家後發現內側略微紅腫。隔天走路時還是會有一點點痛，但只要腳不動就不會痛。

 Mechanism of injury:

Walking. No pain on standing. Pronated Foot, add. and dorsiflexion cause pain.

 Complete medical history過去病史：

There was bruising trauma in the same region because of motorcycle accident in January. The onset was not like the first time. The site of the original condition was the medial region of left ankle, and there has no radiation of the symptoms. The recovery taken two weeks. Spreading on medication（Povidone-Iodine）and dressing relieve symptoms. The current problem is different from previous problem . Previous had a flesh open wound , and current likes mild sprain.

 主要症狀部位：

Medial region of Left ankle。

 現象：

Immobilization and bed can relieves the symptoms. The pain is not remain after walking has stopped.（Level 3: Pain during and after specific activity that dose not affect performance）The problem has existed for two days.

 （以上為point 1-10）

 11. Are the intensity, duration, or frequency of pain or other symptoms increasing?

12. Is the pain constant, periodic, episodic, or occasional? Episodic.(occurring with certain activities)

 

13. The pain is associated with activity.

14. What type or qualty of pain is exhibited? Pain is hard to localize, is dull and aching. Pain is increased when the ankle is stretched.

15. What types of sensations dose the patient feel, and where are these abnormal sensations? Normal.

16. Dose a joint exhibit locking, unlocking, twinges, instability, or giving way? Unlocking.

17.Has the patient experienced any bilateral spinal cord symptoms, fainting, or drop attacks? None.

18. Are there any changes in color of the limb? None.

19. Has the patient been experiencing any life or economic stresses? None.

20. Dose the patient have any chronic or serious systemic illnesses or adverse social habits that may in influence the course of the pathology or the treatment. None.

21. Has the patient undergone an x-ray examination or other imaging technique? None.

22. Is there anything in the family or developmental history that may be related, such as tumors, arthritis, heart disease, diabetes, allergies, and congenital anomalies? None.

23.Has the patient been receiving analgesic, steroid, or any other medication ? None.

24. Dose the patient have a history of surgery or past／present illness? None.

 

(Ankle)

*6. Are symptoms improving, becoming worse, or staying the same? Improving.

*8. What is the patient’s usual activity or pastime? Walking, all-terrain bicycle.

 

*12. What types of shoes dose the patient wear? Pantoffle.