Post 2 WK8 Response Ankle Pain Group C Initial Post

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Post 2 WK8 Response Ankle Pain Group C Initial Post

Response #2

Taylor Schuler 

Ankle Pain Group C Initial Post

COLLAPSE

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Episodic/Focused SOAP Note

Patient information

  • Initials: JB
  • Age: 46 years old
  • Sex: Female
  • Race: Caucasian

Subjective Data:

  • Chief Complaint: Ankle Pain
  • History of Present Illness: JB is a 46-year-old Caucasian female presenting to the clinic with ankle pain. She is more concerned about the right ankle.

The patient was playing soccer and hear a “pop” sound. The patient can bear weight on both ankles, but it is uncomfortable. The patient is complaining of 7 out of 10 pain in the right ankle.

Patient reports bruising and swelling of the right ankle shortly after the “pop” sound. Patient has not taken any medications for the pain. Patient states she did ice her ankle after the event and that seemed to sightly help.

  • Current Medications:
  • Multivitamin daily
  • Ibuprofen 200mg – 400mg every 4 to 6 hours as needed for ankle discomfort
  • Allergies: No known drug allergies
  • Past Medical History: None
  • Past Surgical History:
  • Wisdom teeth extraction at age 17
  • Social History:
  • Denies tobacco and substance abuse
  • Patient drinks 2 to 3 drinks per week socially
  • Patient lives at home with her husband and two children, ages 16 and 18
  • She is a lawyer
  • Her only sexual partner is her husband
  • Attends church most Sundays
  • Eats a heart healthy diet, without adding additional salt to meals
  • Drinks one cup of coffee per day and limits soda consumption
  • Exercises 3 to 4 times per week and plays soccer on the weekends
  • Family History:
  • Mother: Arthritis, diabetes type 2, age 68
  • Father: Hypertension and hyperlipidemia, age 69
  • Maternal Grandmother: Diabetes type 2, obesity, hypertension, passed away at age 81
  • Maternal Grandfather: Asthma, passed away from colon cancer at age 62
  • Paternal Grandmother: Hypertension, MI, and hyperlipidemia, age 94
  • Paternal Grandfather: Hypertension, passed away at age 96
  • Son: None, 18 years old
  • Daughter: Asthma, 16 years old

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  • Review of Systems:

  • General:Denies weight loss. Denies fever or chills. Denies night sweats and sleep disturbances. Denies weakness or fatigue.
  • HEENT:Denies headaches.
    • Eyes:Denies any changes in vision. Currently wears contacts during the day and glasses in the evenings around the house. Denies vision loss, double vision, blurred vision, or yellow sclera.
    • Ears, Nose Throat:Denies changes in hearing and hearing loss. Denies ear pain or discharge. Denies loss of smell or changes in sense of smell. Denies history of nasal polyps. Denies rhinorrhea or sinus infections. Denies sore throat. Last dental exam was 2 months ago. Denies bleeding gums. Wisdom teeth extracted at age 17 without complications.
  • Skin:Denies rashes, moles, or itching. Denies any skin lesions of concern. Attends annual dermatology appointments. Applies sunscreen daily to face. Post 2 WK8 Response Ankle Pain Group C Initial Post
  • Cardiovascular:Denies chest pain and angina. Denies palpitations. Denies any arrhythmias. Denies a history of heart murmur. Denies any peripheral edema.
  • Respiratory:Denies shortness of breath or dyspnea on exertion. Denies hemoptysis.
  • Gastrointestinal:Denies nausea and vomiting. Denies diarrhea, abdominal pain, and constipation. Denies changes in weight or appetite. Denies blood in stool. Denies GERD symptoms. Denies bloating. Denies changes in bowel habits.
  • Genitourinary:Denies burning with urination or blood in urine. Denies history of urinary tract infection. Reports normal vaginal discharge.
  • Neurological:Denies dizziness, tingling, loss of sensation, or memory loss. Denies problems with balance. Denies seizure history. Denies recurrent headaches.
  • Musculoskeletal: Denies history of any muscle weakness or history of breaks.
  • Hematologic:Denies bruising easily. Denies bleeding gums. Denies anemia. Denies history of blood transfusions.
  • Lymphatics:Denies any swollen glands
  • Psychiatric:Denies depression or mood swings. Denies thoughts of hurting herself or others. Feels safe at home. Denies any history of mental illness, drug, or alcohol abuse.
  • Endocrinologic:Denies heat or cold intolerance. Denies excessive thirst or urination. Denies tremors.

Objective Data:

  • Vital Signs:
  • Blood pressure: 114/76
  • Heart Rate: 61
  • O2 Sat: 99% on room air
  • Respiratory Rate: 14
  • Temperature: 98.1 F
  • General: JB is a 46-year-old Caucasian female who is alert and oriented x 4. She is cooperative and responds to questions appropriately. She makes eye contact throughout the conversation. She is a good historian. She is dressed appropriately and appears to have good hygiene practices.
  • Skin: Intact. No lesions or rashes noted. Turgor is good. There is no cyanosis, pallor, or jaundice present.
  • Cardiovascular: Heart rate and rhythm are normal. No murmurs, gallops, or rubs. No bruit auscultated. Bilateral radial pulses 2+.  Left posterior tibial and dorsalis pedis pulses 2+. Right posterior tibial and dorsalis pedis pulses 1+. Peripheral edema and tenderness present at the right ankle.
  • Respiratory: Breath sounds clear to auscultation in all lung fields. Chest wall expansion is symmetrical. No increased effort of breathing.
  • Musculoskeletal: Fully weight bearing with pain to the right ankle. Full range of motion in all extremities except right ankle. Limited range of motion due to stiffness, pain, and edema. No clubbing, cyanosis, or effusions. Edema and ecchymosis present at right ankle and foot. No open lesions and skin intact at right ankle. No calluses or corns present. Strength of the right foot and ankle are weaker than the left.
  • Neurological: Alert and oriented x 4. Mood and affect appropriate for the situation. Sensory intact to pinprick.
  • Diagnostics:
  • Ankle and foot x-rays
  • Stress x-ray
  • MRI
  • Ultrasound

Assessment:

  •  Differential Diagnoses:
  1. Ankle sprain
  2. High ankle sprain and syndesmotic injury
  3. Ankle fracture
  4. Subtalar dislocation
  5. Lisfranc injuries

 

In the case study, the patient presents with right ankle pain after hearing a “pop” sound. With this knowledge, the structures involved in the injury would include the anterior talofibular ligament, calcaneofibular ligament, and posterior talofibular ligament (Melanson & Shuman, 2021).

On average, 70% of ankle sprains involve the lateral ligament complex, and the weakest ligament of that complex is the anterior talofibular ligament (Melanson & Shuman, 2021).

This ligament is commonly injured through the mechanism of plantar flexion and inversion (Melanson & Shuman, 2021). Post 2 WK8 Response Ankle Pain Group C Initial Post

Along with assessing the ankle pain the patient presented with, the advanced practice registered nurse should also assess the affected limb for swelling, bruising, tenderness to touch, and any instability of the ankle (Ball, Dains, Flynn, Solomon, & Steward, 2019).

The provider would initially inspect the ankle and foot while the patient is bearing weight as well as sitting (Ball, Dains, Flynn, Solomon, & Steward, 2019).

The ankle and foot should appear to be smooth and rounded at the prominences without any calluses or corns (Ball, Dains, Flynn, Solomon, & Steward, 2019).

The feet and the tibias should be aligned, and weight bearing should appear on the midline of the feet (Ball, Dains, Flynn, Solomon, & Steward, 2019).

The advanced practice registered nurse should palpate the Achilles tendon, anterior surface of the ankle, and medial and lateral malleoli (Ball, Dains, Flynn, Solomon, & Steward, 2019). The range of motion of the foot and ankle should be assessed as well (Ball, Dains, Flynn, Solomon, & Steward, 2019).

The maneuvers the advanced practice nurse should perform include pointing the foot upward toward the ceiling, then towards the floor, bending the foot at the ankle while turning the foot toward and away from the opposite foot, rotating the ankle, and bending the toes (Ball, Dains, Flynn, Solomon, & Steward, 2019).

The health care provider should also evaluate the strength of each while providing opposing force (Ball, Dains, Flynn, Solomon, & Steward, 2019). While assessing the patient, it is important for the advanced practice registered nurse to use the Ottawa Ankle Rules to determine if the patient needs a radiograph series (Ball, Dains, Flynn, Solomon, & Steward, 2019).

Studies have shown that the Ottawa Ankle Rules have a “98.5% sensitivity for detecting an ankle fracture” (Ball, Dains, Flynn, Solomon, & Steward, 2019).

The rule states there must be pain in the malleolar zone along with either “bone tenderness along the distal 6cm of the posterior edge of the fibula or tip of the lateral malleolus”, “bone tenderness along the distal 6 cm of the posterior edge of the tibia or tip of the medial malleolus”, or the “inability to bear weight for four steps both immediately after the injury and in the emergency department” (Ball, Dains, Flynn, Solomon, & Steward, 2019).

Based on the information provided from the case study, the differential diagnoses for this patient include an ankle sprain, high ankle sprain and syndesmotic injury, ankle fracture, subtalar dislocation, and Lisfranc injuries. The patient presented with right ankle pain along with hearing a “pop” sound when the injury occurred.

Common symptoms associated with an ankle sprain include swelling, bruising, tenderness to touch, pain, and possible instability of the ankle (Haddad, 2016).

With a severe tear of a ligament, it is common for the individual to hear or to feel a “pop” when the sprain occurs (Haddad, 2016). The patient was playing soccer when the injury happened which is one of the known activities someone could unexpectedly twist their foot in an unwanted position (Haddad, 2016).

The other activities this common occurs in includes walking or exercising on an uneven surface, a ground level fall, and participating in sports that require a cutting action (Haddad, 2016).

It is important that this patient seeks medical attention for proper treatment and rehabilitation because long-term effects could include chronic ankle pain, arthritis, or ongoing instability (Haddad, 2016). A high ankle sprain and syndesmotic injury is less common than a lateral ankle sprain (DeWeber, 2021).

Research has shown the only 5.7% of the patients that arrive to the emergency department with an acute ankle sprain without fracture is shown to be a high ankle sprain (DeWeber, 2021). Common symptoms associated with a high ankle sprain include pain that radiates up the leg, bruising, swelling (Jones, 2019).

The patient in the case study reports pain, but the pain does not radiate up the leg. An ankle fracture can result from a twisting motion, falling, or during a car accident (Crist, 2013). The patient, in the case study, was participating in a sport where a twisting motion or rotating her ankle in an unwanted manner could result.

The most common symptoms associated with an ankle fracture include immediate severe pain, swelling, bruising, tender to touch, and unable to bear weight on the effected foot (Crist, 2013). The patient was able to bear weight on her right foot and ankle although it was uncomfortable.

A subtalar dislocation is usually associated with the 5th metatarsal, the talus, or the malleoli (Giannoulis, Papadopoulos, Lykissas, Koulouvaris, Gkiatas, & Mavrodontidis, 2015). This is known to be a rare injury due to the ligament connecting the talus and the calcaneus (Giannoulis, Papadopoulos, Lykissas, Koulouvaris, Gkiatas, & Mavrodontidis, 2015).

The most common symptoms associated with this include deformity, swelling and bruising (Giannoulis, Papadopoulos, Lykissas, Koulouvaris, Gkiatas, & Mavrodontidis, 2015). The patient in the case study did not have a deformity of the right ankle or foot and could bear weight on it. Post 2 WK8 Response Ankle Pain Group C Initial Post

Lastly, Lisfranc injury is an injury that results to the bones or ligaments of the midfoot (Weatherford, 2017). It can be mistaken as a simple sprain (Weatherford, 2017). It is characterized as a low-energy injury from a twist or a fall (Weatherford, 2017).

The most common symptoms associated with a Lisfranc injury include swelling and pain at the top of the foot, bruising at the top and bottom of the foot, and worsening pain when standing and walking (Weatherford, 2017).

The patient in the case study did not have bruising on the top and bottom of her foot, and the pain did not worsen while standing. The most likely diagnosis for this patient would be a simple ankle sprain.

References:

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Steward, R. W. (2019). Seidel’s guide to

physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier

Mosby.

Crist, B. (2013, March). Ankle Fractures (Broken Ankle). Retrieved October 20, 2021, from https://orthoinfo.aaos.org/en/diseases–conditions/ankle-fractures-broken-ankle/.

DeWeber, K. (2021). Syndesmotic ankle injury (high ankle sprain). Retrieved October 20, 2021, from https://www.uptodate.com/contents/syndesmotic-ankle-injury-high-ankle-sprain#H36233279.

Giannoulis, D., Papadopoulos, D. V., Lykissas, M. G., Koulouvaris, P. Gkiatas, I., & Mavrodontidis, A. (2015). Subtalar dislocation without associated fractures: Case report and review of literature. Wolrd journal of orthopedics, 6(3), 374-379. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4390901/ Post 2 WK8 Response Ankle Pain Group C Initial Post

Haddad, S. L. (2016, February). Sprained Ankle. Retrieved October 20, 2021, from https://orthoinfo.aaos.org/en/diseases–conditions/sprained-ankle/.

Jones, E. C. (2019). The High Ankle Sprain: What’s the Difference? Retrieved October 20, 2021, from https://www.hss.edu/conditions_high-ankle-sprain-whats-different.asp.

Melanson, S. W. & Shuman, V.L. (2021). Acute Ankle Sprain. In: StatPearls [Internet]. Treasure

Island, FL: StatPearls Publishing. Retrieved from

https://www.ncbi.nlm.nih.gov/books/NBK459212/.

Weatherford, B. M. (2017, September). Lisfranc (Midfoot) Injury. Retrieved October 20, 2021, from https://orthoinfo.aaos.org/en/diseases–conditions/lisfranc-midfoot-injury/.