Case 2: Ankle Pain Assignment

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 can 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 2: Ankle Pain Assignment

NURS6512 Discussion- Week 8

 

Episodic/focus SOAP Note Template 

Case 1: Back Pain                                      

 

Patient Information

 

Initials: H.H                     Age: 42                  Gender: Male.     Race: Caucasian

 

SUBJECTIVE DATA:

 

Chief Complaint (CC): “Lower Back Pain”

 

History of Present Illness (HPI): Patient is a 42-year-old white male who developed lower back pain that has been bothering him for the past month. He states that the pain radiates to his left leg sometimes, and it increases with sitting for a long period of time but gets better when standing. Severity of pain is 7/10 on pain scale of 0/10.

 

Current Medications: OTC Ibuprofen 300mg 2 tablets every 6hours PRN for Lower back pain.

Amlodipine 10mg 1 tab PO daily for hypertension

 

Allergic/Immunologic: No known drug, food seasonal, latex/rubber allergies

Past Medical History (PMH): Lower Back Pain

Past Surgical History (PSH): None

Sexual/Reproductive History: Single with no kids.

Personal/Social History: Patient works at a storage company as an assistant manager. He enjoys hiking, surfing, and skiing. He reports drinking alcohol on rare occasions, denies illicit drug use and smoking tobacco. He reports a healthy lifestyle including lifting weights three times a week and eating a high protein and low carb diet. Case 2: Ankle Pain Assignment

Immunization History: Influenza 11/1/2020, Pneumovax 05/2020.   Tetanus-Unknown

Significant Family History:

Father: Father is 79 and still living. He has Hypertension, diabetes type 2, and asthma.

Paternal Grandmother: She had hypertension and died at the age of 85.

Paternal Grandfather: Died at the age of 80, had asthma.

Mother: His mother is still alive and has diabetes type 2.

Maternal Grandfather: Died at the age of 80, had type 2 diabetes.

Maternal Grandmother: Died at the age of 85, had a stroke.

Sister: Age 45, has type 2 diabetes.

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Review of Systems:

General: The patient is alert and oriented to person, place, time and situation, appropriately dress according to the weather, good judgement, and a well-nourished Caucasian male. No distress noted but mild discomfort due to pain in his lower back radiating to his left leg. His emotional and behavioral needs are appropriate at the present time considering patient’s clinical condition. Denies current home stress and abuse. Case 2: Ankle Pain Assignment

HEENT:

• Eyes: Patient denies itching eyes or discharges, uses glasses but does not use contact lens, and denies blurred vision.
• Ears: He denies ringing in the ears, hearing loss, and discharged. He also denies surgery to the ears and any recent infections.
• Nose: Denies epistaxis, discharges, congestion, and sneezing. Denies loss of smell.
• Throat: Denies any sore throat, or infection. Denies difficulty swallowing.
• Skin: Negative for skin lesion, mole eczema or rash and no skin changes.
• Neck: No
• Respiratory: Denies shortness of breath, or difficulty breathing, coughing, wheezing, and secondhand smoking.
• Cardiovascular/Peripheral Vascular: Denies chest pain, heaviness, or heart palpitation, and edema to bilateral lower extremities.
• Gastrointestinal: Denies any abdominal upset, nausea or vomiting, have regular bowel movements. Denies change in appetite, and recent weight loss.
• Genitourinary: Denies difficulty voiding, changes in voiding pattern, and any penile discharge.
• Musculoskeletal: Complaints of Lower back pain that radiates down to the left leg. Denies any joint stiffness or joint pain.
• Psychiatric: H.H states that he is fine., denies any mental problems or issues, denies having depression, suicidal thoughts. He states that he loves his wife and family and can never commit suicide. Case 2: Ankle Pain Assignment
• Neurological: denies light headedness, fainting, seizure, vision changes or weakness to any side of his body. Also denies changes in his thinking. Denies syncope, seizures, or tremors. States, pain and burning sensation in left buttocks down left leg past knee.
• Hematologic: Denies any bleeding. Denies history of blood transfusions, clotting disorders, or easy bruising.
• Endocrine: Denies cold or heat intolerance, excessive thirst, or urination, does not have any issues with thyroid. Denies unexplained weight gain or loss, skin dryness or cracking.

 

OBJECTIVE DATA:

Physical Exam:

Vital signs: B/P 148/88; P 75; R 18; T 98.0F orally; 02 SAT 97% on room air; Wt: 155lbs; Ht: 5’11”; BMI: 20.2     Pain 7/10 on a scale of 0-10 at rest.

 

General: Patient is a 42-year-old male who presents as a well-developed young adult at his age. He is alert, oriented, and cooperative. The patient walks with slight limp.

HEENT:

• Head: Normocephalic head with normal distribution of hair. No facial tenderness to light sensation.
• Eyes: Conjunctivas are pink with white sclera and without jaundice. PERLA, with pupils 3mm in size bilaterally. No exudates seen. Corneal light reflex intact. No nystagmus noted. Red reflex present. Optic disc creamy pink with sharp, well defined margins. Retina- pink without vascularization. Case 2: Ankle Pain Assignment
• Ears: Auricles symmetrical bilaterally without pain or tenderness. Use of otoscope visualized external auditory canal, and middle ear showing mild redness and bulging, with serum fluid. Tympanic membranes are pearly grey with bony landmarks and light reflex visualized bilaterally. No drainage from ear, and no facial grimace noted upon examination. Patient is not pulling or tugging on ear or showing signs of distress.

 

• Nose: Nasopharynx and pharynx without erythema, lesion, or exudates. Mucous membranes are moist.
• Throat: Uvula midline, palate rises symmetrically. Oropharynx clear. No sore throat, with swallowing, or enlarge nodes, no redness. Tongue beefy and symmetrical without crusting. Upper, and lower teeth in good condition and intact.
• Skin: Dry and warm to touch. Not pale, cyanosis or ashen. No tear and non-tainting.
• Neck: Normal ROM, Supple with no JVD or bruits. JVD 6cm at 45-degree elevation. Thyroid moves freely with swallow test. No nodules or masses or lesions. No lymphadenopathy. Trachea midline. There is no adenopathy.
• Chest/Lungs: Clear to auscultation bilaterally anteriorly and posteriorly with equal symmetry of chest rise and fall. Breathing appears non-labored. Respiratory excursion 4cm bilaterally. Appears quiet and at ease. No adventitious sounds. Tactile fremitus symmetrical. Resonance noted to percussion bilaterally. No wheezes, rhonchi or stridor. No complaint of SOB, no cough. No pain or tenderness noted over ribs or bony prominence. No pain noted when palpating breasts. No swollen axillary lymph nodes.
• Heart/Peripheral Vascular: The heart rate is regular with a normal rhythm. PMI is heard at the fifth intercoastal space midclavicular line. S1, and S2 normal.  All peripheral pulses are strong and palpable 3+, Negative edema to all extremities. Capillary refill is less than/equal to 2seconds in all extremities and no cyanosis noted or clubbing on nails.
• Abdomen: Soft and nondistended, bowel sound present and active in all four quadrants, no pain or rebound tenderness noted. Last bowel movement was this morning. The liver span percussed to 9cm. No hernias palpated. No hepatomegaly or splenomegaly noted. No renal artery bruits auscultated. Negative McBurney’s point. Case 2: Ankle Pain Assignment
• Musculoskeletal: Spine is vertically aligned. Normal S- curvature. No nodules, masses, or tenderness with palpation. Low back pain radiating to left lower extremity. No evidence of trauma to affected area. Full ROM in all joints. BUE and BLE symmetrical. No pain or tenderness with palpation of joints. Extremities symmetrical without atrophy or hypertrophy. No pain or tenderness with passive ROM. Active and Passive ROM equal between contralateral joints. No crepitation’s or tenderness with movement noted. Case 2: Ankle Pain Assignment
• Neurological: Patient is alert and oriented to place, person, time and situation, appropriate judgement. Speech is clear, no facial drooping, no vision changes, follows movement. Understand clear, complex, comprehensive without cues or repetition.
• Genital/Rectal: Penis and testicles without lesions. No inguinal hernias are present. Rectal exam had intact tone. Firm, symmetric, nontender prostate without nodules.

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Diagnostic Tests:

• Walk across the room to examine abnormalities in gait (pattern of walking).
• Hip flexion and knee hyperextension up to 30 degrees. Bend or flex part of the spine to assess spinal range of motion.
• Complete Blood Count (CBC) may point to infections or inflammation.
• Erythrocyte sedimentation rate
• HLA-B27
• Bone scans
• X-ray of the lumbar spine
• Computerized tomography (CT) cervical spine/lumbar with without contrast to detect abnormal tissue, and the state of the patient’s spine.
• MRI of the lumbar spine to reveal the structure of soft tissues such as discs, spinal cord, and nerves.

 

ASSESSMENT:

 

Differential diagnoses:

Lumbar Disc Herniation (LDH): The intervertebral disc is made up of two parts: an inner nucleus pulposus (NP) and an outer annulus fibrosus (AF) (AF) (Wang et al., 202). The central NP is a site of collagen secretion and contains numerous proteoglycans (PG), which aid in water retention and create hydrostatic pressure to resist axial spine compression. The NP is primarily made up of type 11 collagen, which accounts for 20% of its total dry weight (Wang et al., 2019). The AF, on the other hand, uses a low amount of PG to keep the NP in the center of the disc; 70% of its dry weight is made up of primarily concentric type 1 collagen fibers. In LDH, narrowing of the space available for the thecal sac can occur as a result of disc protrusion through an AF, NP extrusion through the AF while still maintaining continuity with the disc space, or complete loss of continuity with the disc space and sequestration of a free fragment (Wang et al., 2019). This condition is thought to be inherited in approximately 75% of cases; other risk factors include dehydration and Axial Overloading. The role of inflammatory signaling in the production of nerve pain LDH is well known. Radicular pain, sensory abnormalities, and weakness in the distribution of one or more lumbosacral nerve roots are the primary signs and symptoms of LDH. This condition is detected using CT myelography and MRI (Amin, Andrade, & Neuman, (2017). Case 2: Ankle Pain Assignment

Lumbar Spinal Stenosis: The term “Lumbar Spinal Stenosis” refers to a narrowing of the spinal canal in the lower back (Fishchenko et al., 2018). Stenosis, or narrowing, can put pressure on the spinal cord or the nerves that connect the spinal cord to the muscles. In older people, lumbar spinal stenosis (LSS) is most commonly caused by degenerative changes. This condition is typically classified as either primary (caused by congenital abnormalities or a disorder of postnatal development) or secondary (acquired stenosis) when caused by degenerative changes or as a result of local infection, trauma, or surgery (Fishchenko et al., 2018). Anatomically, degenerative LSS can involve the central canal, lateral recess, foramina, or any combination of these locations (Fishchenko et al., 2018). A decrease in the anterior, posterior, transversal, or combined diameter of the central canal can occur as a result of disc height loss, bulging of the intervertebral disc, and hypertrophy of the facet joints and ligamentum flavum Fishchenko et al., 2018). Fibrosis is the most common cause of ligament flavum hypertrophy and is caused by accumulated mechanical stress, particularly along the dorsal aspect of the ligament flavum. The most common symptom associated with LSS is neurogenic claudication, also known as pseudo claudication. Neurogenic claudication refers to leg symptoms that affect the buttocks, groin, and anterior thigh, as well as radiating down the leg to the feet (Wang et al., 2019). Leg symptoms can include fatigue, heaviness, weakness, and/or paresthesia, in addition to pain. The symptoms can be unilateral or bilateral and symmetrical, which is more common. The patient may experience accompanying back pain, but leg pain and discomfort are usually more bothersome (Wang et al., 2019). Case 2: Ankle Pain Assignment

Lumbar Strain/Sprain: The lumbar spine relies on soft tissues to keep the body upright and to support weight from the upper body. When the lower back muscles or soft tissues are overstressed, they can become injured and painful. Lumbar sprain happens when ligaments become overstretched or torn. Ligaments are fibrous, tough tissues that connect bones. Sudden lower back pain is the most common symptom of a lumbar strain. Lower back spasms cause more severe pain, and the lower back feels sore to the touch. Diagnostic procedures for low back pain may include an X-ray, CT scan, and MRI, in addition to a thorough medical history and physical exam (AANS, 2020).

Sciatica: Low back pain is one of the most common conditions seen in clinical practice. Low back pain has significant direct and indirect costs, and it is a common cause of missed work. Sciatica, also known as radiculopathy, is caused by something pressing on the sciatic nerve, which runs through the buttocks and down the back of the leg. Sciatica patients may experience shock-like or burning low back pain, as well as pain through the buttocks and down one leg (AHRQ, 2016).

Spondylolisthesis: It is a spinal condition that affects the spinal bones. This disease causes one of the lower vertebrae to slip forward onto the bone directly beneath it (Genev et al., 2017). It’s a painful condition but treatable in most cases. The symptoms of spondylolisthesis vary. People with mild cases may not have any symptoms. However, those with severe cases may be unable to perform daily activities. Some of the most common symptoms are persistent lower back pain, stiffness in the back and legs, lower back tenderness, thigh pain, and tight hamstring and buttock muscles (Genev et al., 2017). Physical exams are the first step in diagnosing this condition. X-rays of the lower spine are crucial for determining whether a vertebra is out of place. A CT scan may also be ordered if the misplaced bone is pressing on the nerves. The treatment for spondylolisthesis depends on the severity of pain and vertebra slippage. Common nonsurgical treatment methods include wearing a back brace, doing physical therapy exercises, taking anti-inflammatory drugs, or using epidural steroid injections. Surgery may be required if other treatments fail. Case 2: Ankle Pain Assignment

 

Assessing Musculoskeletal Pain

Musculoskeletal pain primarily affects a person’s quality of life through factors such as sleep deprivation, fatigue, depression, and activity restrictions. The set effects are also influenced by contextual factors such as comorbidity, arthritis coping efficiency, and access to care (AANS, 2020). This implies that musculoskeletal (MSK) pain evaluation requires a set of bio-psychosocial perspectives that include pain, baseline effects, and contextual factors.

Back pain nerve roots exhibit a multifaceted, heterogeneous state in which both nociceptive and neuropathic pain mechanisms may be involved. The pain is caused by the activation of nociceptors that innervate ligaments, joints, muscles, fascia, and tendons. This is due to the body’s reaction to tissue injury or even inflammation, in combination with biomechanical stress. The neuropathic pain is caused by an injury or illness that affects the nerve roots innervating the spine as well as the lower limbs, and also pathological invasive innervation within the damaged lumbar discs (Baron et al., 2016).

Within physical assessments, symptoms can be centralized (change in pain along the far end of the entire length of the body region). (A positive test is used to rule out a diagnosis.) Physical examination of the facet joint can also be performed based on centralization and lack of relief from recumbency. The other test is one that centralizes the sacroiliac joint (Peterson et al., 2017). The following test is disc herniation with root involvement, where the dermatological distribution, which mirrors neurological results, improves the set specificity of the outcomes. Spondylolisthesis, fracture, myofascial pain, peripheral nerve, and central sensitization are some of the other tests available. Case 2: Ankle Pain Assignment

References

American Association of Neurological Surgeon. (2020). Low Back Strain and Sprain. Retrieved

ans.org/en/Patients/Nrurosurgical-Conditions-and-Treatment/Low-Back-Strain-and-

Sprain#:

Agency for Healthcare Research and Quality (AHRQ). (2016). Noninvasive Treatments for Low

Back Pain: Current State of the Evidence. Retrieved from

https://effectivehealthcare.ahrq.gov/products/bac-pain-treatment/clinician.

Allegri, M., Montella, S., & Slici, F. (2016). Mechanisms of low back pain: a guide for diagnosis

and therapy. F1000 Research. httpS://doi.org/10.12688/f1000research.8105.1

Amin, R. M., Andrade, N. S., & Neuman, B. J. (2017). Lumbar Disc Herniation. Current review

in musculoskeletal medicine, 10(4), 507-516. https://doi.org/10.1007/s12178-017-9441-4

Baron, R., Binder, A., Attal, N., Casale, R., Dickenson, A. H., & Treede, R. D. (2016).

Neuropathic low back pain in clinical practice. European Journal of Pain, 20(6), 861-

873. https://doi.org/10.1002/ejp.838

Genev, I.K., Tobin, M. K., & Zaidi, S. P. (2017). Spinal Compression Fracture Management: A

Review of Current Treatment Strategies and Possible Future Avenues. Global Spine

Journal, 7(1). https://doi.org/10.1055/s-0036-1583288

Peterson, T., Laslett, M., & Juhl, C. (2017). Clinical classification in low back pain: best

Evidence diagnostic rules based on systematic reviews. BMC Musculoskeletal

             Disorders, 18(188). https://doi.org/10.1186/s12891-017-1549-6

Wang, F., dong, Z., Li, Y. -P., Miao, D. -C., Wang, L. -F., & Shen, Y. (2019). Wedge-shaped

Vertebrae is a risk factor for symptomatic upper lumbar disc herniation. Journal of

Orthopedic Surgery and Research, 14(1). Retrieved from

https://doi.org.ezp.waldenulibrary.org/10.1186/s130-019-13147 Case 2: Ankle Pain Assignment

 

 

 

 

 

 

 

 

 

 

 

 

Create a Power Point Presentation to discuss the following:You have been asked to implement a new computer charting system within your hospital. The staff at the hospital has been using paper charting

Create a Power Point Presentation to discuss the following:

You have been asked to implement a new computer charting system within your hospital. The staff at the hospital has been using paper charting and the staff’s age range is from 20 to 72. You will need to address the following:

1. Who would you want on your team to help you as you implement this change and why? (interdisciplinary team)
2. What should you consider when communicating this change to staff? How should the change be communicated to staff? (in-service, shift meeting)

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3. How are you going to implement the change, handle resistance, and be the change agent?

4. What issues do you need to address about the use of technology within the hospital? (security, website surfing, documentation)
5. What type of technology would you like to see (tablets, laptops, PC’s) why?
6. How do you address the concerns of your staff who do not have a computer and are scared of them?

Power Point should include at least 3 outside references and the textbook. It should include title and reference slides and be 14-20 slides.  

Leadership And Management Paper Example

• • What does it mean to “owe a duty of care”? What are the common clinical practice areas that give rise to allegations of malpractice? What are the most common acts of negligence by nurses?

  For what activities can health care organizations be held liable? What can nurse managers do to help avoid corporate liability?

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 following the APA style guideline 

 500 words  

Site two resources  to complete assignment 

 

Leadership And Management Paper Example

Malnutrition associated with specific health conditions

TOPIC 3: Malnutrition associated with specific health conditions: What specific health conditions increase the risk of malnutrition?

 

Has to be 2-3 pages

 

 

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6817125/

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• Bold for each Heading and Subheading
• Include in-text citations for all information/contents as needed
• Summary paper MUST be written in this format Malnutrition associated with specific health conditions

 

Introduction and Key Points

Chosen Topics and Question

• Select one topic and question from five main topic list

 

Define the Topic and Question

• How do you interpret and/or understand the topic and question you selected?

 

Overview/Significance of Problem

• Describe Overview and Significance of Problem of the topic and question you selected
• Include in-text citations

 

Article Search

Current and credible resourcesList Chamberlain library Database(s) used Malnutrition associated with specific health conditions

 

Database search-terms and methods

 

Number of articles located

 

List additional sources outside of ATI module List all sources you used for article search outside of ATI (CDC, American Diabetic Association, etc.)

 

Article Findings

Why this article chosen?

 

How it addresses the topic?State the “Purpose/Aim of Study” the author stated in article

 

Type of Research conducted

• Quantitative, Qualitative, Descriptive, or Mixed-Method study?
• Briefly describe what was done (sample, methods, measurement tools used)

 

Findings of ResearchComprehensively describe ALLFindings in the article.

 

Evidence for Practice

Summary of Evidence

• Briefly summarize the findings.

 

How will this evidence improve current practice?

• Briefly describe what the current practice is.
• Describe how this evidence improve current practice?

 

How will this evidence decrease a gap in current practice?

• Briefly describe difference between the current knowledge, skills, competence, practice, performance or patient outcomes and the ideal or desirable state
• Describe how this evidence decrease a gap in the practice?

 

Any concerns or weaknesses in the evidence/finding? (Found in Discussion)

 

 

Sharing of Evidence

Who would you share the information with?

 

 

How would you share this information?(in-services, health fair for patients, educate healthcare professionals)

 

 

What resources would you need to accomplish this sharing of evidence?

• List resources you may need for sharing the evidence as you stated in above 2 questions (who and how) (i.e. administrator, manager, support for materials….etc)

 

Why would it be important to share this evidence with the nursing profession?

 

 

Conclusion

• Summarizes the Research processes, Findings, and Key points.
• Do NOT include Conclusion/Implication on the article