Basic Information

Patient name: B. A. A.
Age: 25 years old.
Sex: Female.
Occupation: -

Medical History

Anamnesis: 25-year-old female patient, with no significant personal medical history, presents to the clinic for left ankle pain, intensity 5/10, which appeared about 2 months ago following a road accident.
Family history: None known.

CLINICAL PRESENTATION:

Symptoms: Pain of intensity 5/10 in the left ankle.
Duration: Two months.
Aggravating factors: Walking.
Relieving factors: None.

Treatment History:

Current medication: None.
Previous treatments: None.

Investigations:

Results: Ankle MRI.
Diagnosis: Post-contusion bone edema of the left talus, left calcaneus, left cuboid, and at the level of the left medial and lateral malleoli; rupture of the left anterior talofibular ligament; edema of the posterior talofibular ligament and the deep portion of the deltoid ligament; joint effusion.

Treatment Plan:

Recommended medication: None prescribed.
Therapeutic interventions: 20 hyperbaric therapy sessions.

EVOLUTION AND PROGNOSIS:

Evolution: An approximate 90% reduction in edema was observed.

FINAL OBSERVATIONS:

Significantly improved condition.