Focused SOAP Note: Ankle Pain Case Study Paper

Focused SOAP Note: Ankle Pain Case Study Paper

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Respond to at least two of your colleagues on 2 different days who were assigned different case studies than you. Analyze the possible conditions from your colleagues’ differential diagnoses. Determine which of the conditions you would reject and why. Identify the most likely condition, and justify your reasoning. Focused SOAP Note: Ankle Pain Case Study Paper

Second Response:
“Response exhibits synthesis, critical thinking, and application to practice settings. Provides clear, concise opinions and ideas that are supported by at least two scholarly sources. Demonstrates synthesis and understanding of Learning Objectives. Communication is professional and respectful to colleagues. Responses to faculty questions are fully answered, if posed. Response is effectively written in standard, edited English. Focused SOAP Note: Ankle Pain Case Study Paper

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Focused SOAP Note: Case 2: Ankle Pain

Ankle injuries are common in the game of soccer for both professional and amateur athletes (Kolokotsios et al., 2021). Obtaining a thorough history and conducting an appropriate physical assessment of the patient will help the clinician in determining what interventions are most appropriate for the patient. The purpose of this discussion is to create a focused SOAP Note and differential diagnoses on the following case scenario : Focused SOAP Note: Ankle Pain Case Study Paper

A 46-year-old female reports pain in both of her ankles, but she is more concerned about her right ankle. She was playing soccer over the weekend and heard a “pop.” She is able to bear weight, but it is uncomfortable. In determining the cause of the ankle pain, based on your knowledge of anatomy, what foot structures are likely involved? What other symptoms need to be explored? What are your differential diagnoses for ankle pain? What physical examination will you perform? What special maneuvers will you perform? Should you apply the Ottawa ankle rules to determine if you need additional testing? Focused SOAP Note: Ankle Pain Case Study Paper

Patient Initials: SM Age: 46 Gender: F

S.

CC: “Ankle Pain”

HPI: The patient is a 46-year-old AA, the female who developed sudden onset of ankle pain bilaterally but more concerning on the right side. This pain began this weekend when the patient was playing a soccer game. The pain is described as throbbing and is rated as an 8 out of 10 in terms of intensity. The pain is located in both ankles but more in her right ankle. This pain is accompanied by swelling, erythema and tenderness, and ecchymosis of the right ankle. The patient has been taking 400mg of OTC ibuprofen as needed with minimal relief of her symptoms. Focused SOAP Note: Ankle Pain Case Study Paper

Location: Ankle bilaterally; more so on the right

Onset: This weekend

Character: intermittent throbbing pain after patient heard a “pop”

Associated signs and symptoms: Swelling, erythema, ecchymosis, and tenderness to touch on the right ankle Focused SOAP Note: Ankle Pain Case Study Paper

Timing: while playing a soccer game

Exacerbating/ relieving factors: bearing weight on the ankle(s) is uncomfortable; ibuprofen decreases the pain level temporarily

Severity: 8/10 pain scale

Current Medications:

Ibuprofen (OTC): 400mg every 6 hours, PRN for pain

Metoprolol succinate:25mg every day for hypertension

Wellbutrin XL, 75mg PO every day for MDD Focused SOAP Note: Ankle Pain Case Study Paper

Allergies: no allergies indicated; no environmental allergies, no food allergies, no medication allergies

PMH: Controlled hypertension; Controlled MDD

Surgical Hx: no surgical history

Immunizations: Covid Vaccinations #1 10/2/21 #2 12/1/21 Booster 3/30/22 (Pfizer); Influenza Vaccine 2/9/22; Tetanus booster 2021 Focused SOAP Note: Ankle Pain Case Study Paper

Soc Hx: Occupation: Registered Nurse; hobbies- running, soccer, spending time with family; marital status- married; tobacco use- denies current and previous use; ETOH use- twice a month (beer); Uses cell phone when driving; always wears seat belts when in a motor vehicle; has working smoke detectors in the home; has a supportive family

Fam Hx: Mother living, 70 years old, hx. of hypertension and breast cancer; Father living, 72 years old, hx. type 2 diabetes; Sister 40 years old hx. of breast cancer. Maternal grandmother (deceased) hx. hypertension and diabetes; Maternal grandfather (deceased) hx. heart disease, hypertension, and diabetes, Paternal grandmother (deceased) hx. Asthma, hypertension; Paternal grandfather (living) history of prostate cancer. Focused SOAP Note: Ankle Pain Case Study Paper

ROS:

GENERAL: Negative for weight loss, No weight gain, no fever, + weakness of right ankle, no chills no sweats, no fatigue Focused SOAP Note: Ankle Pain Case Study Paper

HEENT: Eyes: denies visual loss, no blurred vision, no double vision; Ears, Nose, Throat: No hearing deficits, no sneezing, no coughing, no congestion, no rhinorrhea

SKIN: + erythema, ecchymosis, and +2 swelling of right ankle; no rashes, no abrasions no bruising

CARDIOVASCULAR: no syncope, no chest pain, no palpitations, +2 edema of right ankle

RESPIRATORY: No SOB, no hemoptysis Focused SOAP Note: Ankle Pain Case Study Paper

GASTROINTESTINAL: No nausea, No vomiting, no anorexia, no diarrhea. No abdominal pain

GENITOURINARY: no dysuria, no discharge, no burning, no pregnancy. Last menstrual period 04/10/2022.

NEUROLOGICAL: no ataxia, no numbness or tingling in the extremities.

MUSCULOSKELETAL: + pain in the right ankle, decreased ROM of right ankle

HEMATOLOGIC: No bleeding, + bruising of right ankle

LYMPHATICS: No enlarged lymph nodes Focused SOAP Note: Ankle Pain Case Study Paper

PSYCHIATRIC: + for depression, no anxiety, + insomnia due to ankle pain

ENDOCRINOLOGIC: No excessive hunger, no excessive sweating No polydipsia.

O.

VS: BP 130/90; P 84; R16; T 36.9; 02 99%; Wt 82 kg ; Ht 64â€â€

Physical exam:

General: Patient is alert and oriented to person, place, and situation; well-nourished; no acute distress noted; right foot is elevated on a chair

HEENT: normocephalic, PERRLA, no blurred vision, no hearing loss, no JVD, neck supple Focused SOAP Note: Ankle Pain Case Study Paper

Integumentary: warm, dry, pink, no rashes noted, erythema and +2 edema of the right ankle

Cardiovascular: S1, S2 present, hypertensive, regular rate, no murmurs, no gallops appreciated

Respiratory: clear to auscultation, clear to percussion, no SOB Focused SOAP Note: Ankle Pain Case Study Paper

Neurologic: CN II-XII grossly intact, alert, and oriented x4, no deficits noted

Musculoskeletal: limited ROM of right ankle Focused SOAP Note: Ankle Pain Case Study Paper

Peripheral Vascular: positive pulses bilaterally for dorsalis and pedal pulses, the right ankle has +2 edema, the right ankle has erythema, right ankle tender on palpation, ecchymosis of right ankle, no edema or redness noted on the left ankle.

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Diagnostic results: The Ottawa Ankle Rules can be used in cases of an acute ankle injury to help in determining if an ankle radiograph series is needed (Ball et al., 2019). The Ottawa has a 98.5% sensitivity in detecting ankle fractures (Ball et al., 2019). The patient must have pain in the malleolar zone and also: Focused SOAP Note: Ankle Pain Case Study Paper

Inability to bear weight in ED and also for four steps after an injury
Tenderness of bone of distal 6cm posterior edge of the tibia or the tip of the medial malleolus (Ball et al., 2019).
Tenderness of bone of distal 6cm posterior edge of fibula or tip of the lateral malleolus(Ball et al., 2019).
X-ray of lateral and axial calcaneus-( Negative): this can show any calcifications of the bony prominences and also help in ruling out any type of possible bone tumors (Pabon & Naqvi, 2021). Focused SOAP Note: Ankle Pain Case Study Paper

MRI- (Negative) this can show the thickness of the tendon to help in diagnosing tendonitis; this imaging gives information about the state of the joints in the ankle (Pabon & Naqvi, 2021).

Ultrasound (Negative) : This diagnostic test will help to predict the risk of tendinopathy and rupture as well as show the thickness of the Achilles tendon (Pabon & Naqvi, 2021). Furthermore, the ultrasound will show if there is a decrease in the Kager fat pad or a decrease in the gastrocnemius-soleus rotation angle of the ankle (Pabon & Naqvi, 2021). Focused SOAP Note: Ankle Pain Case Study Paper

CT scan (Negative): This test will expose the patient to radiation and may not be needed if the previous scans give enough detail. This test can show trabecular structural alterations of the calcaneus (Pabon & Naqvi, 2021).

Thompson Test ( Negative): This test allows for the examiner to note the degree of plantarflexion at the ankle and if the test is abnormal, it is highly indicative of an Achilles rupture(Shamrock & Varacallo, 2022). Focused SOAP Note: Ankle Pain Case Study Paper

A.

Differential Diagnoses

1) Right Ankle Sprain: It has been found that in the game of soccer, ankle sprains account for roughly 80% of injuries affecting either the external or internal lateral ligaments (Kolokotsios et al., 2021). A cornerstone for diagnosing an ankle sprain is obtaining a detailed history and a proper physical examination of the patient, as imaging is not indicated for most ankle sprains according to Ottawa ankle rules (Halabchi & Hassabi, 2020). All patient situations are different and depending on the examination, imagining may be needed but typically it is not for this type of injury. Furthermore, clinicians should avoid ankle sprain management that includes excessive use of imaging, unwarranted non-weight bearing, and delaying the patient from moving the ankle at all (Halabchi & Hassabi, 2020). Focused SOAP Note: Ankle Pain Case Study Paper A tape measure can be used to measure the swelling in comparison to the uninjured ankle, and anterior drawer and talar tilt tests can be used to detect lateral ankle instability when checking the patient for an ankle sprain (Halabchi & Hassabi, 2020). The symptoms that the patient complains of as well as the findings of the physical assessment indicate edema, erythema, ecchymosis, and pain in the right ankle which are all signs of an ankle sprain. Through history collection and physical assessment, an ankle sprain can be diagnosed. Focused SOAP Note: Ankle Pain Case Study Paper

2) Plantar Fasciitis: This diagnosis occurs more commonly in actively working adults ages 25-65 years old and may present bilaterally as heel pain (Buchanan & Kushner, 2022). This patient is 46 years old and is active in the workforce as she is a registered nurse and also active in sports; she is at risk for this type of injury. The diagnosis of this injury is clinical, and imaging is not needed, however, the provider can order x-rays or ultrasound to evaluate the foot if the injury does not subsite accordingly (Buchanan & Kushner, 2022). Furthermore, an ultrasound would show edema and thickening of the plantar fascia and an x-ray would show calcifications or possibly heel spurs (Buchanan & Kushner, 2022). Focused SOAP Note: Ankle Pain Case Study Paper

3) Achilles Tendonitis: The patient presents with edema, erythema, and tenderness of her right ankle. Warmth, redness, swelling, and pain are all signs of having a joint that is inflamed and can be a sign of tendonitis (Ball et al, 2019). The patient’s Achilles tendon will be palpated as well as the anterior part of the ankle, and the medial and lateral malleoli; a thickened Achilles tendon can be a sign that the patient is suffering from Achilles tendonitis (Ball et al., 2019). Studies show that there is a 2 to 6 cm area proximal to the calcaneal insertion that is hypovascular and a common area for injury (Pabon & Naqvi, 2021). Diagnostic tests that will be suitable for diagnosing this are an MRI and/or an Ultrasound as they will both show the actual thickness of the Achilles tendon. Focused SOAP Note: Ankle Pain Case Study Paper

4) Achilles Tendon Rupture: This diagnosis normally presents with sudden pain and an audible snap or “pop” heard at the injury site (Shamrock & Varacallo, 2022). It has been found that this injury is misdiagnosed as an ankle sprain 20-25% of the time (Shamrock & Varacallo, 2022). During the history and physical, the clinician should compare one ankle to the other while doing the Thompson test; this test can help to assess for tendon continuity and suspected tendon rupture (Shamrock & Varacallo, 2022).  Focused SOAP Note: Ankle Pain Case Study Paper Seeing that the Thompson test was found to be negative, it has been concluded that the patient has indeed sprained her ankle and has not ruptured her Achilles tendon. Furthermore, if the Thompson test was positive, the diagnosis can be confirmed with an ultrasound or an MRI (Shamrock & Varacallo, 2022). Focused SOAP Note: Ankle Pain Case Study Paper

5) Ankle Fracture: The patient presents with pain, edema, and erythema which all can be signs of a fracture however the patient is able to bear weight on her ankle and the pain is located in the back of her ankle and not the malleolar zone, therefore, Ottawa ankle rules state that the radiographs are not needed for this injury (Ball et al., 2019).

P. Focused SOAP Note: Ankle Pain Case Study Paper

The patient will be sent home with an order for an ankle brace and ibuprofen 800mg, every 6 hours as needed for pain and swelling. The patient will also be encouraged to elevate and ice her ankle to help in controlling inflammation as these interventions have been shown to help ankle sprains (Halabchi & Hassabi, 2020). Focused SOAP Note: Ankle Pain Case Study Paper

References

Ball, J. W., Davis, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Seidel’s guide to physical examination: An interprofessional approach (9th ed.). ELSEVIER.

Buchanan, B. K., & Kushner, D. (2022). Plantar Fasciitis. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK431073 Focused SOAP Note: Ankle Pain Case Study Paper

Halabchi, F., & Hassabi, M. (2020). Acute ankle sprain in athletes: Clinical aspects and algorithmic approach. World Journal of Orthopedics, 11(12), 534–558. https://doi.org/10.5312/wjo.v11.i12.534

Kolokotsios, S., Drousia, G., Koukoulithras, I., & Plexousakis, M. (2021). Ankle injuries in soccer players: A narrative review. Cureus. https://doi.org/10.7759/cureus.17228

Pabon, M. M., & Naqvi, U. (2021). Achilles Tendonitis. Stat Pearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK538149/

Shamrock, A. G., & Varacallo, M. (2022). Achilles tendon rupture. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK430844/ Focused SOAP Note: Ankle Pain Case Study Paper