A 46-year-old female reports complaints of bilateral ankle pain with worse pain on the right foot
Your Topic: NURS – 6512C Advanced Health Assessment & Diagnostic Reasoning
Assignment Details: response discussion 2
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.
Collapse SubdiscussionBiftu Ali
Biftu Ali
7:20pmJan 18 at 7:20pm
Episodic/Focused SOAP Note Case # 2
Focused SOAP Note a Patient With bilateral ankle pain is more concerned about her right ankle.
Case # 2: 46, female, no race disclosed
S
CC: Ankle Pain
HPI: A 46-year-old female reports complaints of bilateral ankle pain with worse pain on the right foot after hearing a pop while playing soccer this past weekend. She can bear weight with some discomfort.
Medications: None
PMHx: current with immunization. Flu Vaccine received on 12/30/2022.
FH.
Father: No medical history, happily married for the last 48 years. No surgical history.
Mothe No medical history or surgical history.
Sister: 20-years old college student with no family history.
Paternal Grandfather: Died in a car accident at age 80.
Paternal Grandmother: Died in a car accident at the age of 72.
Maternal Grandfather: died of a stroke at age 90.
Maternal Grandmother: died of COVID at age 85.
SH: no tobacco, alcohol, or illicit drug use. Married for 12 years. Works parttime as an RN. Zero gravida.
Allergies: NKDA
Surgeries: no history of past surgery.
Immunization: Current with immunization. Received COVID 19 # 1 on 3/30/2022, # 2 on 5/30/2022, # 3 on 9/30/2022.
ROS:
General: Negative for fever, fatigue, and chills.
HEENT: No visual loss, hearing loss, no change in the sense of smell, runny nose, no difficulty swallowing
Skin: no rash or itching.
Cardiovascular: Negative for palpitation, chest pain.
Pulmonary: Negative for dyspnea on exertion, cough, or hemoptysis.
Gastrointestinal: Negative for nausea/vomiting, diarrhea, and abdominal pain.
Genitourinary: No hematuria, dysuria
Neurological: No headache or dizziness.
Musculoskeletal: bilateral lower extremities pain and minimum limited range of motion at the right ankle. Normal sensation in all extremities bilaterally. Gait with a slight right-side limp.
Hematologic: No anemia. Edema was noted in the right ankle.
Lymphatic: No history of splenectomy. No enlarged nodes.
Psychiatric: Denies past or present suicidal ideation and homicidal ideation.
Endocrinology: denies polyurea, polydipsia, and polyphase.
O
VS: BP 120/72, P 78, RR 20, T 98.0, O2 100%, Wt. 130, Ht 6’5.”
General: pt alert and oriented x4. Well-groomed. Makes constant eye contact.
HEENT: Head: Normocephalic. Hair is evenly distributed. Eye: PERLA. Ear: patent. Nose: patent. Throat: Uvula midline.
Cardiovascular: No murmur noted. Edema at the right ankle.
Diagnostic Test: X-ray.
The foot structures that are likely involved and other symptoms need to be explored.
Ankle bones, ligaments, or Achilles tendons are likely involved. Other symptoms that need to be explored include edema, tenderness, redness, and range of motion (James & Al-Dadah, 2021). Other information includes the character of pain, frequency, alleviating factor, worsening factor, any medication that was taken, and whether it helps or not. Physical exams include Planter fasciitis test, 2nd metatarsal stress fracture, Interdigital neuroma test, Thompson’s test, and external rotation test (Larkins, 2020).
Differential Diagnosis
Ankle Sprain: the term ankle sprain is used to describe a range of pathology from overstretched ligament to complete tearing of the ligament of an ankle joint (James & Al-Dadah, 2021). Around 90% of ankle sprains involve the foot turning inwards to the anterior talofibular (AFTL) and calcaneofibular (CFL) ligaments. Causes include walking or exercising on an uneven surface, falling or tripping, and participating in sports that requires cutting or jumping actions, such as tail running, basketball, tennis, football, and soccer (James & Al-Dadah, 2021). Symptoms of ankle sprain include tenderness to touch, instability of the ankle, edema, and pain both at rest and with weight bearing or activity (James & Al-Dadah, 2021). Most sprains affect the lateral ligament (Halabchi & Hassabi, 2020). Short-term immobilization following accurate diagnosis will help relieve edema and pain (Vuurberg et al., 2018).
Foot Fracture: Foot fractures are caused by various reasons, including a fall from height (Fitschen-Oestern et al., 2019). Other causes include tripping or falling and injury sustained on jumping (Tan et al., 2020). Foot fractures can be diagnosed by physical exams of bones, joints, or the foot by palpating the foot and a neovascular examination, X-ray, or ultrasound. Signs and symptoms of a foot fracture include edema, tenderness, bruising, pain that worsens with activity, and difficulty walking and standing on the affected foot (Campbell Clinic, 2019).
Ankle Strain: common ankle strain is caused by overstretched or torn muscles and tendons. Pain is the most common symptom of any injury and strained ankles. Other symptoms include inflammation, edema, redness, limited range of motion, or popping. Rest, ice, and compression elevation would help relieve discomfort or pain (Campbell Clinic, 2019).
Ankle Fracture: ankle fractures usually occur due to common excessive twisting mechanisms and a long-term medical condition that affects bone density, such as osteoporosis. Patients usually experience pain with varying intensity and swelling around the ankle region, which may increase as the patient puts weight on the affected ankle (CMRI Kolkata, 2022).
Stress Fracture: stress fractures are common fractures in people who engage in high-impact sports and are caused by inflammation of the periosteum. They are common overuse injuries in athletes and are caused by repetitive sub-maximal loading on a bone over time (Kiel & Kaiser, 2020). They are often seen in running and jumping, and adherents who are associated with increased intensity (Kiel & Kaiser, 2020).
Ottawa Ankle Rules, special maneuvers, and additional testing.
The Ottawa ankle rules are a clinical decision-making strategy for determining which patients require radiologic imaging for ankle and midfoot injuries (Knipe, 2018). This author further states that proper application of the Ottawa ankle rule has high (97.5%) sensitivity and reduces the need for radiographs by 35% (Knipe, 2018). According to (Knipe, 2018), there are two components assessing for ankle and midfoot fractures. A patient with traumatic ankle pain qualified for ankle radiographs if they have any of the following:
Point tenderness at the posterior edge (of distal 6 cm) or lateral tip malleolus.
Inability to weight bear four steps immediately after the injury and in the emergency department.
A patient with traumatic midfoot pain qualified for foot radiographs (Knipe, 2018).
A detailed history and proper physical examination are diagnostic cornerstones (Halabchi & Hassabi, 2020). A thorough history includes the mechanism of injury, and physical inspection should include neurovascular assessment and examination of the soft tissue for signs of open wounds, blanching, edema, and tenting (Lawson et al., 2018). Imaging should be requested based on the Ottawa ankle rules. Recommended interventions include rest, ice, compression, elevation, analgesia, bracing immobilizations, early weight-bearing and walking aids, foot orthoses, manual therapy, and exercise therapy (Halabchi & Hassabi, 2020). Special tests include the anterior drawer test to assess the integrity of the ATFL, range of motion of an ankle, subtalar motion, manual muscle test of plantar flexion, dorsiflexion, inversion, and eversion test, compression test, heel tap test, external rotation test, Thompson’s squeeze test, tibial Torsion test (James & Al-Dadah, 2021).
References
Campbell Clinic. (2019). How to Tell If You Have a Strained, Sprained or Broken Ankle. Campbell Clinic Orthopaedics. https://www.campbellclinic.com/how-to-tell-if-you-have-a-strained-sprained-or-broken-ankle/
CMRI Kolkata. (2022). Ankle Fractures – Symptoms, Causes and Treatments. The Calcutta Medical Research Institute. https://ckbirlahospitals.com/cmri/blog/ankle-fractures. Links to an external site.
Fitschen-Oestern, S., Lippross, S., Lefering, R., Besch, L., Klüter, T., Schenzer-Hoffmann, E., Seekamp, A., & DGU, T. (2019). Missed foot fractures in multiple trauma patients. BMC Musculoskeletal Disorders, 20(1). https://doi.org/10.1186/s12891-019-2501-8Links to an external site.
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.i12.534Links to an external site.
James, J. J., & Al-Dadah, O. (2021). Ankle injuries in athletes: A review of the literature. Www.semanticscholar.org. https://www.semanticscholar.org/paper/Ankle-injuries-in-athletes%3A-A-review-of-the-James-Al-Dadah/1d303a1e1e9c4d1df4d96e5cb1b97302e1522e9dLinks to an external site.
Kiel, J., & Kaiser, K. (2020b). Stress Reaction and Fractures. PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK507835/
Knipe, H. (2018). Ottawa ankle rules | Radiology Reference Article | Radiopaedia.org. Radiopaedia.org. https://radiopaedia.org/articles/ottawa-ankle-rules-1Links to an external site.
Larkins, L. W., Baker, R. T., & Baker, J. G. (2020). Physical Examination of the Ankle: A Review of the Original Orthopedic Special Test Description and Scientific Validity of Common Tests for Ankle Examination. Archives of Rehabilitation Research and Clinical Translation, 2(3), 100072. https://doi.org/10.1016/j.arrct.2020.100072Links to an external site.
Lawson, K. A., Ayala, A. E., Morin, M. L., Latt, L. D., & Wild, J. R. (2018b). Ankle Fracture-Dislocations. Foot & Ankle Orthopaedics, 3(3), 247301141876512. https://doi.org/10.1177/2473011418765122
Tan, J. M., Crossley, K. M., Munteanu, S. E., Collins, N. J., Hart, H. F., Donnar, J. W., Cleary, G., O’Sullivan, I. C., Maclachlan, L. R., Derham, C. L., & Menz, H. B. (2020b). Associations of foot and ankle characteristics with knee symptoms and function in individuals with patellofemoral osteoarthritis. Journal of Foot and Ankle Research, 13(1). https://doi.org/10.1186/s13047-020-00426-8
Vuurberg, G., Hoorntje, A., Wink, L. M., van der Doelen, B. F. W., van den Bekerom, M. P., Dekker, R., van Dijk, C. N., Krips, R., Loogman, M. C. M., Ridderikhof, M. L., Smithuis, F. F., Stufkens, S. A. S., Verhagen, E. A. L. M., de Bie, R. A., & Kerkhoffs, G. M. M. J. (2018b). Diagnosis, treatment, and prevention of ankle sprains: update of an evidence-based clinical guideline. British Journal of Sports Medicine, 52(15), 956–956. https://doi.org/10.1136/bjsports-2017-098106
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