You are an FY2 in the emergency department

Personal Details:

Name: David Chen

Age: 35

Medical Record:

Past medical history: Fit and well.

Notes:

A 35-year-old man presents to the Emergency Department with severe right ankle pain and mild swelling after falling in his garden yesterday. He is unable to bear weight on it.

Task:

1. Take a focused history of the injury, and examine the ankle.

2. Discuss the management plan

Examination finding: ankle redness and swelling, unable to bear weight on his right foot. Limited range of ankle movements because of the pain.

Opening Sentence: “Doctor, I fell in the garden yesterday, and my ankle is killing me. I can’t even put my foot on the ground.”

Open History (to give freely): “I just went over on it. I heard a bit of a pop sound. It swelled up a little bit straight away, and the pain is really bad, a 7/10. I’ve just been resting it with my foot up.”

Cues to give: “I work in a grocery store, so I’m on my feet all day. I’m going to need a sick note.”

ICE (Ideas, Concerns, Expectations):

Ideas: “I think I’ve sprained it, but it could be broken.”

Concerns: “How long will it take to improve? Is it broken?”

Expectation: “I want to know if it’s broken, and I need something for the pain and a sick note for work.”

How to Act: You are in genuine pain and are worried about how this will affect your ability to work.

More History (only if asked): You are otherwise fit and well.

Social History: Works in a grocery store, a physically demanding job.

Questions to ask:

“So you don’t think I need an X-ray?”

History of the Injury:

Tell me exactly how the injury happened. Which way did your foot roll - inwards or outwards? Did you hear a crack or a pop? Where exactly is the pain? Can you point to the most painful spot? Were you able to put any weight on it immediately afterwards? Can you put any weight on it now?

ICE (Ideas, Concerns, Expectations): What did you think you had done to your ankle? What’s your biggest worry about this injury? You were expecting an X-ray. What were you hoping that would show?

Examination (Applying Ottawa Rules): I’m going to gently feel some specific points on your ankle. Please tell me if it’s tender when I press. (Palpate the posterior edge of the lateral malleolus, the posterior edge of the medial malleolus, the base of the metatarsal, and the navicular bone). Are you able to take four steps, even if you are limping?”

Explain the likely diagnosis or DD:

I’ve examined your ankle carefully, and after my assessment, it is difficult to fully exclude the possibility of a fracture. I will arrange for you to have an X-ray today. To look for any features that might suggest a fracture.

Addressing and answering the patient’s ICE:

You’re asking how long it will take to improve. This will depend on the X-ray results. But roughly you can expect it to be painful and swollen for the first one to two weeks, but you should see a gradual improvement. It might take six to eight weeks before it feels strong again.

Next Steps:

I will get you some strong painkillers now (morphine). Have you had any side effect for morphine in the past? It occasionally makes people feel sick and have itching, so I will give you some antihistamine for that.

We will decide the next step based on the X-ray result. If it showed features of a fracture, I would involve the orthopaedic team to assess this further. If it is just a strain, then this could be managed by a painkiller, applying cold water, rest and allowing it time to heal and recover.

You should take regular painkillers like paracetamol and ibuprofen. After the first few days of rest, it’s important to start gentle mobilisation exercises to stop the ankle from getting stiff. We can give you a leaflet showing you some simple exercises to do.

Sick note

You are absolutely right that you will not be able to do your job. I will provide you with a sick note, or a ‘fit note’, for two weeks initially. It will state that you are not fit for work. If you are still unable to work after two weeks, you can see your GP for a further note.

Addressing ideas, concerns, and expectations, arrange an X-ray, and agree to give a sick note.

What is scenario testing? This case tests the candidate’s knowledge and application of a clinical decision rule (Ottawa Ankle Rules). It also tests their ability to provide clear self-care advice for a common musculoskeletal injury and to manage the social aspects of the consultation (issuing a sick note).