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[ANSWERED] 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

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 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?

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 

  1. Ankle Sprain– Most possible condition
  2. Ankle fracture
  3. Arthritis
  4. Tendon injury
  5. 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

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