Nursing

To prepare:

By Day 1 of this week, you will be assigned to one of the following specific case studies for this Discussion. Please see the “Course Announcements” section of the classroom for your assignment from your Instructor.
Your Discussion post should be in the Episodic/Focused SOAP Note format rather than the traditional narrative style Discussion posting format. Refer to Chapter 2 of the Sullivan text and the Episodic/Focused SOAP Template in the Week 5 Learning Resources for guidance. Remember that all Episodic/Focused SOAP notes have specific data included in every patient case.
Review the following case studies

ANSWER

Episodic/Focused SOAP Note

Patient Information:

The patient, Ms. J.D. is a 46-year-old white female woman who huts her ankle playing soccer over the weekend and describes hearing a ‘pop’ sound on the right ankle. She can manage her weight on the ankles but feels uncomfortable especially on the right one.

S.

CC “Both of my ankles are hurting, but my right ankle hurts more”

HPI:

Ms. J.D. is a 46-year-old white female who works at the community recreation center as an assistant to the coach of the community soccer team. Today she presents with bilateral ankle pain that has bothered her for three days now. The patient states that she was kicking a soccer ball in practice this past weekend when she thought she heard a clear “pop” sound. She reports initially having felt a 3/10 bilateral pain in her ankles but noticed after walking on it that the pain intensified especially on the right one. She states that she is able to bear weight on both of her ankles, but she feels discomfort on the right ankle. Cold compresses have relieved some of the pain in both ankles. However, today she reports the pain to be between 4 and 5/10 on the right ankle and a 2/10 on the left one.

Current Medications: Multivitamin, takes two chews per day for about 15 seconds to boost her appetite. Albuterol inhaler 90mcg (base)/actuation PRN which she uses as an emergency rescue inhaler.

Allergies: Morphine Sulfate- which triggers urticarial reactions in her. She is also allergic to pollen and dust which triggers her asthmatic reactions.

PMHx: She received a tetanus vaccine as a child and a Flu vaccine on February of 2020. Suffers from mild asthma which she was diagnosed with as a child and uses her Albuterol rescue inhaler PRN to suppress but she says she only has to use it once every six months.

Soc Hx: The patient is single and not previously married. She works as a full-time assistant to a community soccer coach at a recreation center. She does not smoke or use any tobacco products but drinks occasionally. She is physically active as she enjoys cycling three days a week. Patient reports wearing a helmet when cycling.

Fam Hx: Patient is an only child and reports that there is no known hereditary condition in her family, and is able to trace her lineage up to four generations before her. Both of her parents are alive and she does not have any children.

ROS:

GENERAL:  Patient is pleasant and fully cooperative while answering questions. Patient does not report any changes in her weight.

HEENT:  Eyes:  No visual loss, double vision or blurred vision. Ears, Nose, Throat:  No hearing loss, sneezing, congestion, runny nose or sore throat.

SKIN:  No rash or itching.

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

RESPIRATORY:  Occasional shortness of breath and coughs but no sputum. Patient was diagnosed with asthma as a child and occasionally uses an inhaler.

GASTROINTESTINAL:  No anorexia, nausea, vomiting or diarrhea. No abdominal pain or blood. Patient also reports having a normal bladder pattern.

GENITOURINARY:  Patient denies burning on urination and pregnancy

NEUROLOGICAL:  No headache, dizziness, syncope, paralysis, ataxia, numbness or tingling in the extremities. No change in bowel or bladder control.

MUSCULOSKELETAL:  Patient reports ankle pain on both legs and especially on the right leg. The pain started three days ago and ranges between 2 and 5 over 10. Patient can bear her weight, but feels discomfort.

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.

ALLERGIES:  Diagnosed with asthma, and is allergic to all sulfur products.

O.

Physical exam:

Vital signs: BP 116/72, Pulse 62 (regular and strong), RR 16 and non-labored, Temp 98.4 F oral, SpO2 99% on room air, HT 5’7” WT 145 lbs.

General: A & O x 4, pleasant, and cooperative. Does not appear to be in any serious form of distress.

Chest/Lungs: CTA AP&L, equal and bilateral expansions. Normal S1 and S2. No S3, S4 or murmurs. Regular rhythm.

Heart/Peripheral Vascular: RRR without murmur, rub, or gallop; pulses+2 bilateral pedal and +2 radial; no edema. No clubbing or cyanosis. Capillary refills normally.

Neuro: Alert and oriented x4. Strength and sensation intact. CN II – XII grossly intact.

Musculoskeletal: Pain on both ankles. Ecchymosis on lateral aspect of malleolus area and tenderness on palpitation on lateral aspect of ankle over the anterior talofibular ligament. ROM limited with pain on inversion, dorsiflexion, and plantar flexion. Can bear weight on both ankles, but feels pain on the right one. No deformities noted.

Skin/Lymph Nodes: 2×1.5cm ecchymosis on mid-lateral malleolus area of the right ankle.

Diagnostic results:

X- Ray of RT ankle: An x-ray of the ankle should be done when pain is present in the malleolar area with one of the following locations (Ball et al., 2015). The X-ray revealed bony tenderness to the distal 6cm of the posterior edge or tip of the lateral malleolus, bony tenderness on the distal 6cm of the posterior edge or tip of the medial malleolus, or the inability for the patient to be weight bearing.

Anterior Drawer Test: The anterior drawer test is a screening test used for assessing the ankle for lateral ankle sprains and a suspected anterior talofibular ligament injury (Kaminski, 2013).

A.

Differential Diagnoses

1. Grade 2 Lateral Ankle Sprain. An ankle sprain, according to The American College of Foot and Ankle Surgeons, is an injury that occurs to one or more of the ligaments in the ankle that produces symptoms like pain, swelling, bruising, soreness, joint stiffness, and difficulty walking (ACFAS, 2018). Sports injuries are very common when running, landing a jump, or any direct contact that can create pain, swelling, and even an audible tearing or popping, yet ecchymosis can be delayed by a few days (AOFAS, 2015). The patient’s presentation and their symptoms are consistent with that of an ankle sprain.
2. Tendinitis in the Achilles. Tendinitis is an inflammation in the Achilles tendon that causes the patient to experience pain, tenderness, and swelling in the area where the tendon meets the calcaneus which can also create issues with walking or running (Baumann et al., 2016). The patient does present with pain and discomfort walking, but there was no swelling noted on the exam which would be present in the posterior area of the ankle.
3. Ankle Fracture. The fracture can be in several different bones that are all located in the ankle. The American Academy of Orthopedic Surgeons reports that an ankle fracture can occur in the tibia, fibula, or talus. Fractures in these bones will cause the patient to experience severe pain, swelling, tenderness, deformity, bruising, and the inability to bear weight on the ankle. This is not likely for the patient as she can bear weight, it is just not comfortable.
4. Plantar Fasciitis. Plantar Fasciitis “which affects women twice as often as men, is caused by chronic weight-bearing stress when laxity of foot structures allows the talus to slide forward and medially, calcaneus to drop, and plantar ligaments and fascia to stretch” (Baumann et al., 2016, p. 269). This is not likely to be the diagnosis as plantar fasciitis is more painful when the patient wakes up and can be relieved with stretching and other non-weight bearing activities.
5. Anterior Impingement. Anterior impingement is more commonly referred to as “footballer’s ankle” and requires a detailed history to diagnose as it cannot be seen on an x-ray or MRI. This is caused when the “friction of bone and soft tissue within a joint or within the periarticular spaces” (Green & McCabe, 2018, p. 61). This can cause some of the symptoms A.B. is experiencing such as decreased range of motion in the ankle, but more information into past medical history would be necessary for this diagnosis.

References

American College of Foot and Ankle Surgeons. (2018). Ankle Sprain. www.foothealthfacts.org/conditions/ankle-sprain

American Orthopedic Foot & Ankle Society. (2015, June). Ankle Sprain. www.aofas.org/PRC/conditions/Pages/Conditions/Ankle-Sprain.aspx

Ball, J. W. et al. (2015). Seidel’s guide to physical examination (8th ed.). St. Louis, MO: Elsevier Mosby.

Baumann, L. C. et al. (2016). Advanced health assessment and clinical diagnosis in primary care .St. Louis, MO: Elsevier Mosby.

Kaminski, T. W. et al. (2013). National Athletic Trainers’ Association Position Statement: Conservative Management and Prevention of Ankle Sprains in Athletes. Journal of Athletic Training, 48(4), 528-545.