Case 2: Ankle Pain

 

Case 2: Ankle Pain

 

 

Student’s Name

Department Affiliation, University Affiliation

Course Number: Course Name

Instructor’s Name

Assignment Due Date

 

 

 

 

 

 

 

 

 

 

 

Episodic/Focused SOAP Note

 

Patient Information:

Initials T.P , Age: 46 years, Sex: Female, Race: White

S.

CC ” I have pain in both my ankles, but more concerned about the right ankle.”

HPI: T.P. is a forty-six-year-old white female patient who presents to the facility complaining of having pain in both her ankles. She, however, indicates that she is more concerned with her right ankle. The patient was playing soccer when she heard a “pop” sound. While she can bear weight, she does so uncomfortably. She indicates that the patient is sometimes throbbing and achy, especially over the right ankle lateral aspect. The patient rates the patient as a four out of ten when resting. The patient radiates up the right lower extremity, and the patient reported some swelling after hearing the sound. Her left ankle also has some little pain, but it is not of immediate concern.

Current Medications: The patient has no current medications

Allergies: No known allergies either to the environment, food, or medication.

PMHx: The patient reports to be getting an annual flu vaccine and has been getting every appropriate immunization since childhood

Soc Hx: The patient is married, and they currently have two children, a boy, and a girl, 17 years old and 12 years old, respectively. She is an accountant in a local firm and likes playing soccer. She denies ever smoking or drinking, and she loves a vegetarian diet, even though she occasionally uses flesh.

Fam Hx:

The patient’s father died of diabetes and hypertension while the mother is still alive and eighty years old. She has a history of depression and severe rheumatoid arthritis.  She has two elder sisters (55 years and 50 years) and a younger brother who is forty years. All her grandparents are deceased, and they had a history of hypertension and arthritis.

ROS:

GENERAL:  the patient denies weight loss, fever, chills, weakness, or fatigue.

HEENT:  Eyes: the patient denies double vision, blurred vision, or visual loss. Ears, Nose, Throat:  she also denies hearing loss, sneezing, congestion, runny nose, or sore throat.

SKIN:  No bruising, itching, or rash.

CARDIOVASCULAR: The patient denies chest discomfort, chest pressure, or chest pain. No edema or palpitations.

RESPIRATORY: The patient denies cough, breath shortness, or sputum.

GASTROINTESTINAL:  Denies abdominal pain, vomiting, nausea, or anorexia.

GENITOURINARY:  Denies pregnancy, no pain or burning upon urination.

NEUROLOGICAL:  The patient denies numbness, ataxia, paralysis, dizziness, or headache. MUSCULOSKELETAL:  The patient confirms bilateral ankle pain, more pronounced on the right ankle than the left ankle. The right ankle is swollen, and she struggles to bear weight. The patient also denies a lower range of motion to bilateral ankles.

HEMATOLOGIC:  Denies bleeding or anemia.

LYMPHATICS:  No history of splenectomy; denies enlarged nodes.

PSYCHIATRIC: no history of anxiety or depression, or any other mental illness.   ENDOCRINOLOGIC: No Polydipsia or polyuria.

ALLERGIES:  Denies history of rhinitis, eczema, hives, or asthma.

O.

Physical exam:

Vital signs: BP: 116/75, Temp: 97.5, RR: 18, HR: 72, Height: 5.5, Weight: 125 lbs

General: The patient is neatly dressed, well-developed, and nourished. She is alert and oriented. However, she reports some discomfort which is connected to the patient she has been experiencing in her right ankle.

HEENT: The head is atraumatic and Normocephalic. No ear discharge or pain, no vision loss, no running nose. The neck is supple.

Skin: bruising to the right lateral ankle. No skin rashes or wounds. The skin is dry and warm.

Chest: The lungs are clear. No dyspnea or cough. Regular heart rate and beat, no extra sounds, no murmurs or gallops.

The musculoskeletal system: The patient’s right lateral ankle is swollen. The ankle has a lowered motion range and weakness. Some tenderness was noted on palpation of the fibula’s lower aspects. There is also bruising to the right ankle lateral aspects. Non-tenderness to the right ankle medial aspects. The left ankle has no tenderness, bruising, or swelling. She bears weight with pain in the right leg.

Diagnostic results: Ottawa Ankle rule is applied in identifying the need for testing when there is ankle pain. The instrument is key in determining if the patient’s ankle pain needs further assessment.

Differential Diagnoses

1. Right ankle sprain: This condition usually results from the activity and can be severe or mild. The patient, in this case, study, was playing soccer which resulted in her hearing a pop. The next was pain and swelling. Therefore, this is one of the likely diagnoses. An ankle sprain usually presents with various symptoms, such as difficulty walking, joint stiffness, soreness, bruising, swelling, and pain (Herzog et al.,2019). The patient presented with some of these symptoms. The Ottawa ankle rule can be key in determining if the patient needs to perform further ankle radiographs; since the patient could walk even though in pain, it would not be necessary to go for further radiographs.
2. Chronic Ankle Instability: This is another possible diagnosis. In the case of multiple ankle sprains, a patient may experience chronic instability, which makes them prone to acute inversion injuries. Some of the symptoms include injury and re-injury to the ankles for more than half a year, clinical instability, swelling, and pain (Hertel & Corbett, 2019). The patient presented with pain and swelling to the right ankle, making this condition a possible diagnosis.

• Achilles tendon injury: this is a condition that comes due to a sudden snap in the lower calf. Some of the symptoms include pain in the back of the leg, pain aggravated with activity, sore and stiff Achilles tendon, and swelling (Chan et al.,2020). The patient showed some of these symptoms; hence this is also a possible diagnosis.

1. Ankle fracture: ankle fractures result from ankle stress. Some of the symptoms include the inability to bear weight, bruising, and swelling. It is usually observed in the metatarsal, navicular, and calcaneus bones. The patient presented with pain and swelling, which makes this a possible diagnosis.
2. Post-exercise muscle soreness: This is a condition that presents with pain or discomfort to the distal part of the skeletal muscles after undergoing physical activity. Decreased flexibility and strength are also observed. The patient had pain when playing soccer, making this condition a possible diagnosis.

 

 

 

 

 

References

Chan, J. J., Chen, K. K., Sarker, S., Hasija, R., Huang, H. H., Guzman, J. Z., & Vulcano, E. (2020). Epidemiology of Achilles tendon injuries in collegiate level athletes in the United States. International Orthopaedics, 44(3), 585-594. https://doi.org/10.1007/s00264-019-04471-2

Hertel, J., & Corbett, R. O. (2019). An updated model of chronic ankle instability. Journal of Athletic Training, 54(6), 572-588. https://doi.org/10.4085/1062-6050-344-18

Herzog, M. M., Kerr, Z. Y., Marshall, S. W., & Wikstrom, E. A. (2019). Epidemiology of ankle sprains and chronic ankle instability. Journal of Athletic Training, 54(6), 603-610. https://doi.org/10.4085/1062-6050-447-17