Pt is a 19 year old male who presents today for 2 week follow-up of his left medial

malleolus fracture. Pt states he has been weight-bearing on his boot since that time.
He denies changes in sensation, numbness or tingling. Pt denies pain at this time. Pt
states he does have some pain after walking around his college campus all day but
states that it is minimal.

Some minimal swelling and dryness is noted to the medial aspect of the left ankle. Pt
is nontender to palpation over the medial malleolus. ROM with flexion and
extension is normal. Pt does have capillary refill of 2 seconds. Normal sensory exam.

ASSESSMENT/PLAN: X-rays were ordered and reviewed with the indication of

medial malleolus fracture. AP/Lateral/Oblique views on radiograph do show some
consolidation of the fracture. At this time we would like to continue with weight
bearing in his boot and would like to see him back in 4 weeks for follow-up.