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.”
The body is constantly sending signals about its health. One of the most easily recognized signals is pain. Musculoskeletal conditions comprise one of the leading causes of severe long-term pain in patients. The musculoskeletal system is an elaborate system of interconnected levers that provides the body with support and mobility. Because of the interconnectedness of the musculoskeletal system, identifying the causes of pain can be challenging. Accurately interpreting the cause of musculoskeletal pain requires an assessment process informed by patient history and physical exams.
In this Discussion, you will consider case studies that describe abnormal findings in patients seen in a clinical setting.
To prepare:
- 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 study:
Case 1: Back Pain
A 42-year-old male reports pain in his lower back for the past month. The pain sometimes radiates to his left leg. In determining the cause of the back pain, based on your knowledge of anatomy, what nerve roots might be involved?
How would you test for each of them? What other symptoms need to be explored? What are your differential diagnoses for acute low back pain? Consider the possible origins using the Agency for Healthcare Research and Quality (AHRQ) guidelines as a framework. What physical examination will you perform? What special maneuvers will you perform?
Case 2: Ankle Pain
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?
Case 3: Knee Pain
A 15-year-old male reports dull pain in both knees. Sometimes one or both knees click, and the patient describes a catching sensation under the patella. In determining the causes of the knee pain, what additional history do you need? What categories can you use to differentiate knee pain? What are your specific differential diagnoses for knee pain?
What physical examination will you perform? What anatomic structures are you assessing as part of the physical examination? What special maneuvers will you perform?
With regard to the case study you were assigned:
- Review this week’s Learning Resources, and consider the insights they provide about the case study.
- Consider what history would be necessary to collect from the patient in the case study you were assigned.
- Consider what physical exams and diagnostic tests would be appropriate to gather more information about the patient’s condition. How would the results be used to make a diagnosis?
- Identify at least five possible conditions that may be considered in a differential diagnosis for the patient.
Post an episodic/focused note about the patient in the case study to which you were assigned using the episodic/focused note template provided in the Week 5 resources. Provide evidence from the literature to support diagnostic tests that would be appropriate for each case. List five different possible conditions for the patient’s differential diagnosis, and justify why you selected each.
Rubric Detail
| Excellent | Good | Fair | Poor | |||
| Main Posting | 45 (45%) – 50 (50%) “Answers all parts of the Discussion question(s) with reflective critical analysis and synthesis of knowledge gained from the course readings for the module and current credible sources. Supported by at least three current, credible sources. Written clearly and concisely with no grammatical or spelling errors and fully adheres to current APA manual writing rules and style. | 40 (40%) – 44 (44%) “Responds to the Discussion question(s) and is reflective with critical analysis and synthesis of knowledge gained from the course readings for the module. At least 75% of post has exceptional depth and breadth. Supported by at least three credible sources. Written clearly and concisely with one or no grammatical or spelling errors and fully adheres to current APA manual writing rules and style. | 35 (35%) – 39 (39%) “Responds to some of the Discussion question(s). One or two criteria are not addressed or are superficially addressed. Is somewhat lacking reflection and critical analysis and synthesis. Somewhat represents knowledge gained from the course readings for the module. Post is cited with two credible sources. Written somewhat concisely; may contain more than two spelling or grammatical errors. Contains some APA formatting errors. | 0 (0%) – 34 (34%) “Does not respond to the Discussion question(s) adequately. Lacks depth or superficially addresses criteria. Lacks reflection and critical analysis and synthesis. Does not represent knowledge gained from the course readings for the module. Contains only one or no credible sources. Not written clearly or concisely. Contains more than two spelling or grammatical errors. Does not adhere to current APA manual writing rules and style. | ||
| Main Post: Timeliness | 10 (10%) – 10 (10%) Posts main post by Day 3. | 0 (0%) – 0 (0%) N/A | 0 (0%) – 0 (0%) N/A | 0 (0%) – 0 (0%) Does not post main post by Day 3. | ||
| First Response | 17 (17%) – 18 (18%) “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. | 15 (15%) – 16 (16%) “Response exhibits critical thinking and application to practice settings. Communication is professional and respectful to colleagues. Responses to faculty questions are answered, if posed. Provides clear, concise opinions and ideas that are supported by two or more credible sources. Response is effectively written in standard, edited English. | 13 (13%) – 14 (14%) “Response is on topic and may have some depth. Responses posted in the Discussion may lack effective professional communication. Responses to faculty questions are somewhat answered, if posed. Response may lack clear, concise opinions and ideas, and a few or no credible sources are cited. | 0 (0%) – 12 (12%) “Response may not be on topic and lacks depth. Responses posted in the Discussion lack effective professional communication. Responses to faculty questions are missing. No credible sources are cited. | ||
| Second Response | 16 (16%) – 17 (17%) “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. | 14 (14%) – 15 (15%) “Response exhibits critical thinking and application to practice settings. Communication is professional and respectful to colleagues. Responses to faculty questions are answered, if posed. Provides clear, concise opinions and ideas that are supported by two or more credible sources. Response is effectively written in standard, edited English. | 12 (12%) – 13 (13%) “Response is on topic and may have some depth. Responses posted in the Discussion may lack effective professional communication. Responses to faculty questions are somewhat answered, if posed. Response may lack clear, concise opinions and ideas, and a few or no credible sources are cited. | 0 (0%) – 11 (11%) “Response may not be on topic and lacks depth. Responses posted in the Discussion lack effective professional communication. Responses to faculty questions are missing. No credible sources are cited. | ||
| Participation | 5 (5%) – 5 (5%) Meets requirements for participation by posting on three different days. | 0 (0%) – 0 (0%) N/A | 0 (0%) – 0 (0%) N/A | 0 (0%) – 0 (0%) Does not meet requirements for participation by posting on three different days. | ||
| Total Points: 100 | ||||||
Expert Answer and Explanation
SOAP Note
Patient Information:
S.
CC “the patients mentions that she feels pain her ankles, more so in her right leg.”
HPI: Mrs. M is a 46-year-old female patient who has visited the medical facility reporting that she feels pain in her ankles, and has increased in her right leg. The patient mentions that she started feeling pain after hearing a “pop” sound when playing football during the weekend. The pain is rated six out of ten because she can bear weight lifts although she feels unconfutable while doing so. The patient tried applying naproxen sodium pain reliever but the situation has not reduced.
Current Medications: Naproxen sodium.
Allergies: She allergic to red meat. The patient is also allergic to dust, and can develop respiratory problems when exposed to the agent.
PMHx: She was vaccinated against swine flu two months ago. Also, the patient mentions that she often receives malaria vaccine in case she wants to travel the disease prone areas, such as Africa.
Fam Hx: The patient’s mother died from fatal car accident and the father is suffering from HBT and arthritis. She is married with three children who are both healthy with no pre-existing condition. However, the husband has diabetes which is well controlled.
SH: The patient does not use any hard drugs or alcohol. She likes sporting and going to church. The patient loves travelling when she is on holidays. Her favorite vacation destination is Africa.
ROS:
GENERAL: The patient tests negative for chills, fatigue, fever, and nausea.
HEENT: She has no running nose, hearing problem and visual issues.
CARDIOVASCULAR: Her circulation system is healthy.
RESPIRATORY: Negative for any respiratory condition.
MUSCULOSKELETAL: Pain in the ankle.
GASTROINTESTINAL: Negative for vomiting, nausea, and diarrhea.
O.
Physical exam: Palpation and observation was used to physically examine the patient. palpation showed that ecchymosis was present in the patient’s leg and that it was tender. Also, the examination revealed that the CFL and ATFL ligament areas were tender and swollen. Observation shows that the patient can carry body weight but her face shows the feeling of pain.
Diagnostic tests and results: Talar tilt test and anterior drawer test can be used to diagnose patients with ankle pain (Qwaider & Abu Naser, 2017). Anterior drawer test showed that suction or dimple is present on the ATFL area. Also, talar tilt test showed that the CFL of the right foot was damaged because firm endpoint was not felt.
A.
Differential Diagnoses
- Ankle Sprain– Most possible condition
- Ankle fracture
- Arthritis
- Tendon injury
- Sinus tarsi syndrome
Reasons for Selecting Ankle Sprain
Ankle sprain is the most possible condition affecting the patient. According to Evers et al. (2016), the condition occurs when one’s ankles twists, roll, or turns in an abnormal manner. The condition can be treated by the patient but required a profession in case the pain is severe. The pain occurs when the ankle ligaments are overstretched (Evers et al., 2016).
The disease has been selected as the primary diagnosis because the patient feels pain, especially when she nears weight. Also, during physical examination the patient was found not to walk properly and her ankle is unstable. The other four diagnoses also cause ankle pain (El-Zawawi et al., 2017). However, they were ruled out because they cause total inability to walk.
References
El-Zawawi, M. S., Ebied, O. M., & Sileema, E. R. A. (2017). Role of magnetic resonance imaging in the diagnosis of ankle impingement. Menoufia Medical Journal, 30(1), 99. DOI: 10.4103/mmj.mmj_323_15
Evers, J., Wähnert, D., Grüneweller, N., Raschke, M. J., & Ochman, S. (2016). Delayed Surgical Reconstruction of a Peroneal Tendon Rupture in an Accessory Os Peroneum: A Rare Differential Diagnosis in Chronic Ankle Pain. Journal of the American Podiatric Medical Association, 106(6), 439-444. https://doi.org/10.7547/15-092
Qwaider, S. R., & Abu Naser, S. S. (2017). Expert System for Diagnosing Ankle Diseases. International Journal of Engineering and Information Systems (IJEAIS). Retrieved from https://www.researchgate.net/profile/Samy_Abu-Naser/publication/319208547_Expert_System_for_Diagnosing_Ankle_Diseases/links/599bfc62aca272dff128fd9c/Expert-System-for-Diagnosing-Ankle-Diseases.pdf
Alternative Expert Answer and Explanation
SOAP Note
Patient Information:
S.
CC “pain in both ankles, especially in the right ankle.”
HPI: Patient AA is a 46-year-old female who came to the hospital complaining of pain in both her ankles, especially the right one. She reports that the patient started moments after she heard a “pop” sound while playing soccer over the weekend. Though she can lift weight, she fills pain during the exercise. The pain can be measured to be 6/10.
Current Medications: aspirin tablets.
Allergies: No allergies.
PMHx: Has not reported any immunizations.
Fam Hx: Her mother and father suffer from arthritis.
ROS:
GENERAL: Feels a pain in her ankles, more so in the right ankle.
HEENT: Healthy.
CARDIOVASCULAR: Healthy.
RESPIRATORY: Healthy.
LYMPHATICS: No enlarged nodes.
MUSCULOSKELETAL: Pain in the ankles.
O.
Physical exam: When her vitals were measured it was found that the patient has body temperature of 37.2 degrees centigrade, HR 77 beats/min, RR 18, BP 116/90, and FVC 1.78. Also, she appears tired and stressed.
Diagnostic results: According to Landry et al. (2020), thompson test, squeeze test, and talar tilt test are the tests that will be used to examine the pain to find the possible medical problem.
A.
Differential Diagnoses
Lateral Ligament Injury– Most possible condition
Sinus tarsi syndrome
Ankle instability
Distal Fibula Fracture
Gout and Pseudogout
Reason for Selecting Lateral Ligament Injury
According to Landry et al. (2020), lateral ligament inquiry occurs when there is a sprain in one’s ligaments at the joint. According to the authors, one with lateral ligament inquiry can conduct daily activities though with a lot of discomfort. The condition largely occurs during athletics practices (Murray et al., 2018). The lateral ligament injury has been selected as the most possible diagnosis because the patient argues that she started feeling pain moments after hearing a “pop” sound when playing soccer.
References
Landry, M. E., Gabriel, S., Clifford, A. G., & Lowe, D. (2020). U.S. Patent No. 10,531,897. Washington, DC: U.S. Patent and Trademark Office. https://patents.google.com/patent/US10531897B2/en
Murray, C., Marshall, M., Rathod, T., Bowen, C. J., Menz, H. B., & Roddy, E. (2018). Population prevalence and distribution of ankle pain and symptomatic radiographic ankle osteoarthritis in community dwelling older adults: a systematic review and cross-sectional study. PloS one, 13(4). doi: 10.1371/journal.pone.0193662
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Ottawa Ankle Rules in Clinical Practice
In nursing practice, efficient and accurate assessment of musculoskeletal injuries, particularly ankle injuries, is paramount. The Ottawa Ankle Rules (OAR) serve as a valuable tool for clinicians in determining the necessity of radiographic imaging in patients presenting with ankle injuries. Developed to aid in clinical decision-making, understanding and correctly applying the OAR can significantly improve patient outcomes by reducing unnecessary radiation exposure, healthcare costs, and patient wait times. This article aims to provide nurses with a detailed overview of the Ottawa Ankle Rules, including their components, applications, and relevance in pediatric populations.
What are the 5 Ottawa Ankle Rules?
The Ottawa Ankle Rules consist of a set of clinical criteria used to determine whether ankle radiography is warranted following an ankle injury. The five criteria are as follows:
- Tenderness along the posterior edge or tip of the lateral malleolus.
- Tenderness along the posterior edge or tip of the medial malleolus.
- Inability to bear weight both immediately and in the emergency department for four steps.
- Tenderness over the navicular bone.
- Tenderness over the base of the fifth metatarsal.
What is the Foot Ottawa Rule?
The Foot Ottawa Rule is an extension of the Ottawa Ankle Rules and focuses specifically on foot injuries. It helps clinicians determine the necessity of foot radiography following an injury. The rule states that foot radiography is indicated if there is tenderness in the midfoot region or the base of the fifth metatarsal.
What age does the Ottawa Foot Rules apply?
The Ottawa Foot Rules typically apply to adults and older children. However, their applicability in pediatric populations may vary depending on the individual patient’s age, developmental stage, and injury mechanism. For younger children, clinical judgment and consideration of additional factors may be necessary when deciding whether radiographic imaging is warranted.
What is the Ottawa Ankle Rule Surface Anatomy?
Understanding the surface anatomy pertinent to the Ottawa Ankle Rules is crucial for accurate assessment. The lateral malleolus refers to the bony prominence on the outer aspect of the ankle, while the medial malleolus is the bony prominence on the inner aspect. The navicular bone is located on the medial aspect of the foot, just proximal to the first metatarsal. The base of the fifth metatarsal is situated on the outer aspect of the foot, distal to the ankle joint.
Ottawa Ankle Rules Pediatrics
In pediatric patients, the application of the Ottawa Ankle Rules requires careful consideration due to anatomical differences, variations in injury patterns, and challenges in clinical assessment. While the rules were primarily developed and validated in adult populations, studies have suggested their potential utility in pediatric patients. However, clinicians must exercise caution and rely on clinical judgment when applying the Ottawa Ankle Rules in pediatric practice. Factors such as age, developmental stage, and mechanism of injury should be taken into account, and imaging decisions should be made on a case-by-case basis.
Conclusion
The Ottawa Ankle Rules are invaluable tools for nurses in the assessment of ankle and foot injuries. By adhering to these evidence-based guidelines, nurses can streamline clinical decision-making, reduce unnecessary radiation exposure, and optimize patient care outcomes. While the rules offer a structured approach to injury assessment, clinicians must remain vigilant and consider individual patient factors, particularly in pediatric populations, to ensure safe and effective care delivery. Continued education and training in the application of the Ottawa Ankle Rules are essential for nurses to enhance their clinical skills and promote best practices in musculoskeletal injury management.
