Review of Case study 2
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Episodic/Focused SOAP Note
JO, 46-year-old female, African American
CC: Pain in both ankles, but more concerned about her right ankle.
HPI: The patient is a 46-year-old African American female who presents to the clinic with complaint of bilateral ankle pain, but more concerned about her right ankle. Patient reports that she heard a pop come from her right ankle while playing soccer 3 days ago over the weekend, and ever since her right ankle has become increasingly uncomfortable. She is able to bear weight but it is uncomfortable when standing or walking. Patient described the pain as a dull uncomfortable pain and she rates the pain as 7/10 to the right ankle and 3/10 to the left ankle. She believes that the right ankle is bruised and swollen. She reports that she takes Ibuprofen and Tylenol alternately for pain and swelling and it makes it tolerable. Pain is aggravated whenever she puts weight on it to stand or walk but feels better when she is seated with her right foot raised.
Ibuprofen 600mg every 8 hours as needed for the pain
Tylenol 1000mg every 4 hours as needed for pain
One-A-Day Womenâ€™s Multivitamins one tablet daily
Ferrous Sulfate 325mg once daily
Allergies:Â Denies any drug, food, latex or seasonal allergies
PMHx: Osteoarthritis (diagnosed 7 years ago), Type 11 DM and HTN (diagnosed 3 years ago). Right total knee replacement (3 years ago). Received influenza vaccine this season, Current on Covid and other vaccines. Last Tdap 11/25/2020. No recent hospitalizations
1)Primary Diagnosis is Ankle Sprain:
An ankle sprain is an injury to one or more ligaments in the ankle with symptoms such as pain, swelling, soreness, bruising, limited range of motion and joint stiffness (Dains, Baumann, & Scheibel, 2019). It is an inversion-type twisting of the foot, followed by pain and swelling (Young, 2019). This type of injury is often associated with physical activities or sports. Sports injuries occur when running, cutting, landing from a jump, or from direct contact which can produce an audible tear or pop causing pain and swelling that are immediate, but ecchymosis may lag a day or two behind (American Orthopedic Foot & Ankle Society, 2021).Â JO has most of these symptoms and is able to bear weight which rules out a more complex structural injury or fracture.
2)Â Bursitis: Bursitis can be described as the acute or chronic inflammation of a bursa that results in localized pain, tenderness, and swelling over the bursa (Maffulli, et al, 2018). Other symptoms that are associated with this condition is low-grade temperature, the warmth of overlying skin, and a palpable bump over heel (Maffulli et al., 2018).
3)Â Plantar fasciitis: This affects women twice as often as men. It is caused by chronic weight-bearing stress when laxity of the foot structures allows the talus to slide forward and medially, calcaneus to drop, and plantar ligaments and fascia to stretch (Dains, et al., 2019). Pain is worse on awakening and is relieved with non-weight bearing activity, often involving the heel (Baumann, et al., 2016).
4)Â Ankle Fracture: An ankle fracture produces diffuse swelling surrounding the injured bone immediately following injury (Dains et al., 2019). In some cases of a fracture, a visible deformity can be observed on inspection if the fracture is displaced. This can be ruled out as JO heard a popping sound with the injury and is weight bearing.
5)Â Achilles tendon ruptures: An Achilles tendon rupture can parallel symptoms associated with ankle sprains. An Achilles tendon rupture should be suspected if the patient experiences an extensive amount of swelling, bruising or pain (Young, 2019). Furthermore, swelling associated with a ligament rupture occurs within minutes of the injury.
American Orthopaedic Foot & Ankle Society (2021). Ankle Sprains While Running: Symptoms and Treatment.Â Â https://www.aofas.org/news/press-releases/2021/08/19/ankle-sprains-while-running-symptoms-and-treatment
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2015). Seidel’s guide to physical examination (8th ed.). St. Louis, MO: Elsevier Mosby.
Dains, J. E., Baumann, L. C., & Scheibel, P. (2019). Advanced health assessment and clinical diagnosis in primary care (6th ed.). St. Louis, MO: Elsevier Mosby
Maffulli, N., Longo, U. G., & Denaro, V. (2018).Â Bursitis. Retrieved fromÂ Â https://online.epocrates.com/diseases/52311/Bursitis/Key-Highlights
Young, C. (2019). Medscape: Ankle sprain. Retrieved fromÂ Â https://emedicine.medscape.com/article/1907229-overview
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