Health Assessment Ubiquitous Lateral Ankle Sprain Discussion

Episodic/Focused SOAP Note Template

Patient Information:

G.M. 46 yo white female

S.

CC: ankle pain x 4 days after traumatic event

HPI: 46 year old white female presents to the clinic today complaining of bilateral ankle pain. Patient is complains of more intense pain in the right ankle at this time. Aching pain reported by patient to the right ankle. Standing makes pain worse, resting makes pain better, pain is a 6/10 on the pain scale. Pt states was playing soccer over the weekend and heard a “pop”. The patient is able to bear weight on both ankles but is uncomfortable. Pain is reproducable upon palpation. pt has been wrapping ankle at home with ace bandage with minimal pain relief. pt had not used any medications for pain intervention.

Current Medications: pt is on no medications at this time.

Allergies: Pt has no drug, food, or environmental allergies. Health Assessment Ubiquitous Lateral Ankle Sprain Discussion

PMHx: Pt has no significant PMHx. Pt is up to date on all vaccinations. Pt has had no major surgeries.

Soc Hx: Patient does not drink alcohol, use illicit drugs, or use tobacco products. Pt is active. Pt exercises regularly. Pt has a balanced diet.

Fam Hx: mother hx of hypertention, father history of hyperlipidemia, two teenage daughters both in good health

ROS:

GENERAL: No chills, no fatigue. Health Assessment Ubiquitous Lateral Ankle Sprain Discussion

CARDIOVASCULAR: No chest pain, chest pressure or chest discomfort. No palpitations or edema.

RESPIRATORY: no cough, sputum, or SOB.

NEUROLOGICAL: No headache, dizziness, syncope, paralysis, ataxia, numbness or tingling in the extremities. No change in bowel or bladder control.

MUSCULOSKELETAL: Pt complains of pain to the ankles bilaterally, more intense on the right. Pt able to bear weight, although uncomfortable. 6/10 aching pain reported by pt.

SKIN: no lesions, no rash, or itching.

O.

BP 122/76 P. 87 RR. 16 T. 98.4 F O2 99% RA H. 5’ 1” Wt 140 lbs.

General: Pt appears comfortable sitting in a chair, calm and cooperative, dressed appropriately, in good mood.

Cardiovascular: Heart sounds heard appropriately. S1,S2 heard. No rubs, murmurs heard. No clubbing, cyanosis, or edema noted.

Neuro: equal strengths bilaterally, no numbness, no ataxia. no decreased sensation in extremities.

Respiratory: Pt has clear lung sounds throughout, equal symmetrical movement throughout

Musculoskeletal: Pt has swelling to the lateral region of the right ankle. Pt has limited ROM to the right ankle. Able to bear weight and walk four steps. Toes are straight, no bruising noted to toes or metatarsals. No pain upon palpation of the fifth metatarsal. Tenderness noted to the anterior-inferior tibiofibular ligament. Positive pulses found in the Dorsalis Pedus artery. Pt able to stand on ball of foot with moderate amount of pain reported.

Skin: skin intact, no lesions, no rash. Health Assessment Ubiquitous Lateral Ankle Sprain Discussion

Diagnostic results: using the Ottawa tests we can discern if the patient is in need of a xray. Upon examination if the patient had pain in the malleolar zone and unable to bear weight or bony tenderness from the edge of the tibia or fibia and to the tip of the medial malleoulus or lateral malleolus (Gomes, et al, 2020). Xray Needed to RO fracture.

CT: CT may be needed to more accurately evaluate bone and some soft tissue if Xrya is inconclusive. Health Assessment Ubiquitous Lateral Ankle Sprain Discussion

A.

Differential Diagnoses

Ankle Sprain- Ankle sprain is an over-stretching of the ligaments of the ankle. Symptoms include swelling, tenderness, and bruising (Newsham, 2019). The patient heard a “pop” which is indicative of a possible sprain.

Fracture of the talus- Fracture of the talus is a fracture that can be displaced or non displaced. In this instance a non displaced fracture of the talus would be suspect. Although the patient would most probably not be able to bear weight on this type of injury, it is possible.

Achilles Tendenitis- Achilles Tendenitis will cause ankle pain and decrease ROM. This patient is at low risk of Achilles tendinitis because of location of pain is not at the Achilles tendon where it inserts in to the calcaneus (Dains, Baumann, Scheibel, 2019).

Achilles Tendon rupture- Achilles tendon rupture is a complete or partial tear of the tendon. Patients can hear a pop folled by a sharp pain in the ankle. Ankle swelling can be present. Unlikely in this patient because of her ability to stand on her toes.

Plantar fasciitis- Plantar fasciitis is a condition of chronic weight-bearing stress which allows the talus to slide forward and medially and plantar ligaments and fascia begin to stretch because of structure movement within the lower extremity (Dains, Baumann, Scheibel, 2019). Pain is more severe when patient is weight bearing. The patient is at low risk of this because of the immediate pain from a traumatic event and because of the lack of heel pain. Health Assessment Ubiquitous Lateral Ankle Sprain Discussion

P.

This section is not required for the assignments in this course (NURS 6512) but will be required for future courses.

References

Gomes YE, Chau M, Banwell HA, Davies J, Causby RS. 2020. Adequacy of clinical information in X-ray referrals for traumatic ankle injury with reference to the Ottawa Ankle Rules—a retrospective clinical audit. PeerJ 8:e10152 https://doi.org/10.7717/peerj.10152

Newsham, K. (2019). The Ubiquitous Lateral Ankle Sprain: Time to Reconsider Our Management? The Journal for Nurse Practitioners, 15(5). doi:10.1016/j.nurpra.2019.01.019

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.

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