Episodic/Focused SOAP Note- Mrs. J.J

Episodic/Focused SOAP Note- Mrs. J.J

Patient Information:

Mrs J.J, a 46-year-old White Female

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S.

CC: “ankle pain both legs, worse in the right leg for three days.”

HPI: The 46-year-old White female came to the hospital complaining of pain that began three days ago, over the weekend, after an injury during a soccer game. The injury sustained in the game produced a pop sound in her right ankle. She can bear weight but is uncomfortable and rates the pain at 5 out of 10.

She describes the pain as pressure on her right ankle, which worsens after sitting for a while and when climbing staircases. Massage using hot water has not been helpful. She also took OTC Ibuprofen, but the pain is not subsiding

Current Medications: OTC Ibuprofen 200mg PO TDS

Allergies: Allergic to dust- has a runny nose, sneezing, and eye irritation

PMHx: Immunization up to date. Last tetanus dose two years. Diagnosed with diabetes at 35 and uses exercise and diet to control the condition

Soc Hx: Does not drink alcohol, smoke tobacco, or do other drugs. The patient admits to using safety seat belts and has a fire and intruder alarm system for her safety. She lives with her husband and three kids. She is a high school teacher and loves playing soccer, choir practice, jogging, and riding a bicycle in her free time. She identifies her family and the church as her strong social supporters.

Fam Hx: Her mother, 65, is alive and well and living with diabetes. Her father, 68, has epilepsy and Lewy body dementia. Her brother, 40, is diabetic, obese, and hypertensive.

ROS:

GENERAL: Denies any recent weight loss, fever, fatigue, or chills

HEENT: Head: Denies headache, hair loss or any head injuries.  Eyes: Denies any visual changes such as loss, blurry, or double vision. Nose: Denies any running nose, congestion, or pain. Ears- denies loss of hearing, pain, or loss of balance. Throat: Denies pain swallowing,

SKIN: Denies itching, swelling, lesions, or easy bruising.

CARDIOVASCULAR: Denies chest pain, chest discomfort, or edema

RESPIRATORY: Denies coughing, shortness of breath, or congestion

GASTROINTESTINAL: Denies nausea, vomiting, diarrhea, or constipation. No blood in stool or urine.

GENITOURINARY: Denies pain or burning sensation on urination. LMP 30^th September 2022, 2 weeks ago

NEUROLOGICAL:  Denies headache, dizziness, syncope, numbness, and ataxia. No blood or bowel control changes

MUSCULOSKELETAL: Denies muscle and joint pain or stiffness. Reports bilateral ankle pain, which is more severe in the right ankle resulting from an injury during a soccer game

HEMATOLOGIC:  No anemia, bleeding or bruising.

LYMPHATICS:  No enlarged nodes. No history of splenectomy.

PSYCHIATRIC:  No history of depression or anxiety.

ENDOCRINOLOGIC:  No reports of sweating, cold or heat intolerance. No polyuria or polydipsia.

O.’

Vital signs: BP 131/88; P 67; R 13; T 36.6⁰C; Sp02 96%: WT: 65kg; HT 168cm

Physical exam

General: The patient is well-oriented, dressed to the occasion, and appears relaxed and in a good mood. Grimace or when changing leg positions

Cardiovascular: The apex and peripheral pulse rates are 67 beats per minute. S1 and S2 with no murmurs. Capillary refill of <2 seconds

Respiratory: Symmetrical chest movement with breathing. Vesicular breath sounds auscultated. No crackles or wheezes auscultated. Resonant sound to percussion

Musculoskeletal: Both extremities ate bilaterally equal. The patient exhibits a full range of motion on other joints except for the ankles. The right ankle is visibly swollen, with bruising and skin discolouration. Tenderness on palpation with a grimace due to pain. Thompson test is negative, plantar flexion positive, Talar tilt <3mm on the lateral side, negative squeeze and anterior drawer tests

Diagnostic results: The diagnostic results include an ankle’s posterior, anterior, and lateral X-ray. Bohler’s angle is between 20⁰ and 40⁰

A.

Differential Diagnoses

The primary diagnosis is a sprain. A sprained ankle involves injury to a tendon or ligament in the ankle. The most important symptoms are an inability to bear weight on the affected side, pain, bruising, tenderness, and skin discolouration. The patient presents with bilateral pain but claims that the right ankle is more painful than the left ankle.

Chen et al. (2019) note that an ankle sprain occurs during activity and results from excessive twisting of a ligament hence ankle instability causing the pop sound. Various maneuvers and tests are necessary to differentiate between a sprain and other injuries. The severity of injuries can deceive on the type of the injury, especially for hindfoot bones. Thus, a thorough physical exam, health history, and diagnostic tests are necessary for a definitive diagnosis and management.

A high ankle sprain is a possible diagnosis for this patient. A high ankle sprain occurs when tendons and ligaments are above the ankle stretch, leading to an injury. A squeeze test reveals a high ankle sprain. Prakash (2020) notes that a high ankle sprain presents with pain in walking, inability to bear weight, and problems with gait. The patients also present with significant bruising above the ankle, which is absent in this patient. A high ankle sprain may cause significant movement problems hence the need for its attention

One major differential diagnosis is calcaneus fracture. Smitaman and Davis. (2022) note that a calcaneus fracture is caused by axial loading. Its effects can be severe, often preventing an individual from walking or bearing weight. Fractures can also be mild, depending on the degree. The patient can walk and only has a problem bearing weight.

An ankle x-ray reveals a decreased Bohler’s angle and excruciating pain. However, a normal Bohler’s angle does not eliminate the possibility of a calcaneus fracture. An X-ray often helps reveal the fracture’s size and characteristics, which is not visible in this case ruling out the diagnosis. The talar twist, anterior drawer, and squeeze tests can be painful depending on the severity of the fracture.

A talus bone fracture results from an injury to the talus bone: the talus is on the foot bones. The bone’s fracture can produce a pop sound and leads to swelling and pain in ankle movement. People with a talus fracture have problems with weight bearing and often walk with difficulty for up to 12 weeks (Schwartz et al., 2020). However, the pain is much more severe and causes immobilization for some time.

Most often, it is an emergency; again, the symptoms depend on the severity. Pain in a talus fracture is mostly in the anterior side of the ankle. However, the pain intensity rules out the diagnosis. In addition, the injury requires a high-velocity injury, such as a car collision accident. In addition, the pain is more medial than in the posterior

This section is not required for the assignments in this course (NURS 6512) but will be required for future courses.

References

Chen, E. T., McInnis, K. C., & Borg-Stein, J. (2019). Ankle sprains evaluation, rehabilitation, and prevention. Current sports medicine reports, 18(6), 217-223. https://doi.org/10.1249/JSR.0000000000000603

Prakash, A. A. (2020). Epidemiology of high ankle sprains: A systematic review. Foot & Ankle Specialist, 13(5), 420-430. https://doi.org/10.1177/1938640020916266

Schwartz, A. M., Runge, W. O., Hsu, A. R., & Bariteau, J. T. (2020). Fractures of the talus: current concepts. Foot & ankle orthopaedics, 5(1), 2473011419900766. https://doi.org/10.1177/2473011419900766

Smitaman, E., & Davis, M. (2022). Hindfoot Fractures: Injury Patterns and Relevant Imaging Findings. RadioGraphics, 42(3), 661-682. https://doi.org/10.1148/rg.210167