ADV HEALTH ASSESSMENT
NURS 6512: Advanced Health Assessment and Diagnostic Reasoning
Week Eight: Assessment of the Musculoskeletal System
Case study #2: Ankle Pain
Scenario: KC 46-year-old African American female present with reports of pain to both ankles,
states she’s 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 Ottowa ankle rules to determine if you need additional testing?
Episodic/Focused SOAP Note for Throat Exam
Patient Information: K.C. Age: 46 Y/O. Sex: Female DOB: 3/6/1972
S.
Chief Complaint: Having pain to both my ankles but more severe the right.
History of Present Illness:
K.C. is a 46-year-old African American female who presented pain to her bilateral ankle for the
past 2 days. Patient reported while playing soccer this past weekend she heard a “pop” sound
during the game. The pain appears to be worse on to her right ankle, she is able to bear weight on
both ankles but states having more pain and discomfort to her right ankle when walking or
standing. Patient been applying cold compress which provides some relief, she now noticed
increased swelling to her bilateral ankles more so to her right ankle.
Current Medications:
Tylenol ES 500mg 2tabs BID as needed
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Multivitamins one tablet daily
Allergies: Nuts-hives
Immunization History: Flu Vaccine September 2017
Past Medical History (PMH):
Fam Hx: Reported both parents are healthy and alive. Father has hypertension.
Personal/Social History: Patient is single. Works as a physical education teacher fulltime. Does not smoke, drink or use any illicit drugs. Physically active, exercises 5-6 time
a week.
Review of Systems:
Constitutional: A&O x4, pleasant and cooperative. No acute distress. Denies weight loss,
weakness, or fatigue.
HEENT: Denies headache, sore throat or changes in vision and hearing.
SKIN: No rash or itching.
CARDIOVASCULAR: Denies chest pain or palpitations.
RESPIRATORY: Denies shortness of breath or cough.
GASTROINTESTINAL: Denies abdominal discomfort. Reported having regular daily
bowel pattern.
GENITOURINARY: Bilateral ankle pain for the past 48 hours, more severe on right
ranging 4-5/10. Swelling started past 24 hours. Able to bear weight but with discomfort.
NEUROLOGICAL: Denies focal loss of strength or loss of sensation.
MUSCULOSKELETAL: Denies focal weakness, facial droop, or joint swelling.
HEMATOLOGIC: Diagnosed with anemia 2 years ago. Regularly checked by her
primary care physician and managed by prescribed supplements. No bleeding or bruising.
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LYMPHATICS: No enlarged nodes. No cervical lymphadenopathy
O.
Physical exam: Vital signs: B/P 126/72, Pulse 68 (strong and regular); Temp 98.0F orally;
RR 19; non-labored; SpO2: 98% room air;
Height: 5' 4" Weight:122 lbs.
General: A&O x4, pleasant and cooperative. Not in any acute distress.
HEENT: Normocephalic and atraumatic. Sclera anicteric, No conjunctival erythema,
PERRLA. Oropharynx red. No lesions. Moist mucous membranes.
Neck: Supple. No JVD. Trachea midline. No pain, swelling or palpable nodules.
Chest/Lungs: Clear to auscultation bilaterally. No accessory muscle use.
Heart/Peripheral Vascular: Right ankle swelling. Regular rate and rhythm noted. No
murmurs. No palpitation. No clubbing or cyanosis; Normal capillary refill. Bilateral equal
pedal pulses.
ABD: Soft, nontender, nondistended. No rigidity, rebound, or guarding. No palpable
hepatosplenomegaly.
Genital/Rectal: continent of bladder and bowel.
Musculoskeletal: Lower extremities with reports of pain. Right ankle swelling and
2x1.5cm ecchymosis on mid-lateral malleolus area with tenderness upon palpation on the
lateral side of the ankle over the anterior talofibular ligament (ATFL). Range of motion
with pain and limitation on dorsiflexion, plantar flexion, and inversion. Skin intact. Able
to bear weight on BLE, with discomforts on the right ankle. No bony tenderness,
deformity or crepitus present.
Neuro: Alert and oriented x4. Strength and sensation intact.
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Skin/Lymph Nodes: 2x1.5cm ecchymosis on mid-lateral malleolus area of the right ankle.
Intact skin. No cervical lymphadenopathy. No rashes, or erythema. No lesions.
Diagnostic studies:
Anterior Drawer Test: positive
An Anterior Drawer Test is considered as a screening test in the assessment of lateral
ankle sprain and suspected ATFL injury (Croy, Hertel, Koppenhaver, & Saliba, 2013).
Inversion test: pain noted in the area of anterior talofibular ligament.
Imaging Studies:
Right ankle X-ray
- According to the rule, an ankle X-Ray series is only required if there is any pain in the
malleolar zone plus one of the following: bone tenderness along the distal 6cm of the
posterior edge of the fibula or tip of the lateral malleolus bone tenderness along the distal
6cm of the posterior edge or tip of the medial malleolus or an inability to bear weight
both immediately and in the emergency department for four steps (Ball, Dains, Flynn,
Solomon, & Stewart, 2015, p. 252).
A.
Differential Diagnoses (DD):
• Grade 2 Lateral Ankle Sprain: 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 Orthopaedic Foot &
Ankle Society, 2015).
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- An ankle sprain is an injury to one or more ligaments in the ankle with symptoms
such as pain, swelling, soreness, bruising, difficulty walking, and joint stiffness
(American College of Foot and Ankle Surgeons, 2018).
- Based on the reported symptoms and physical assessment findings, ankle sprain is the
primary diagnosis for the patient. Anteroposterior lateral views x-ray preferably with
weight bearing or during inversion will reveal extent of ligament injury.
• Achilles tendinitis inflammation of the Achilles tendon producing symptoms of pain and
swelling where the tendon inserts into the calcaneus, and patient reports of feeling of tightness
that makes walking and running difficult (Baumann, Dains, & Scheibel, 2016, p. 269).
- The area of pain and tenderness noted with G.M. involves mid-lateral area of the
ankle. Swelling of the Achilles tendon can be assessed in the posterior part of the
ankle.
• Ankle fracture: may involve the one or more of the ankle bones such as tibia, fibula, and talus
with symptoms such as severe immediate pain, swelling, bruising, tenderness, deformity, and
inability to bear weight (American Academy of Orthopaedic Surgeons, 2013).
• Anterior impingement: which is also known as footballer’s ankle with presenting symptoms
such as pain and inflammation including decrease in overall ankle range of motion, mostly
affecting dorsiflexion (Stanford Health Care, 2017).
• Plantar fasciitis: affect women twice as often as men, is caused by chronic weight-bearing
stress when laxity of foot structures allows the talus to slide forward and medially, calcaneus to
drop, and plantar ligaments and fascia to stretch (Baumann, Dains, & Scheibel, 2016, p. 269).
Pain is worse on awakening and is relieved with non-weight bearing activity often involving the
heel (Baumann, Dains, & Scheibel, 2016, p. 269).
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Reference
American Academy of Orthopaedic Surgeons. (2013). Ankle Fractures. Retrieved from
https://orthoinfo.aaos.org/en/diseases--conditions/ankle-fractures-broken-ankle/
American College of Foot and Ankle Surgeons. (2018). Ankle Sprain. Retrieved from
https://www.foothealthfacts.org/conditions/ankle-sprain
American Orthopaedic Foot & Ankle Society. (2015, June). Ankle Sprain. Retrieved from
http://www.aofas.org/PRC/conditions/Pages/Conditions/Ankle-Sprain.aspx
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.
Baumann, L. C., Dains, J. E., & Scheibel, P. (2016). Advanced health assessment and clinical
diagnosis in primary care (5th ed.). St. Louis, MO: Elsevier Mosby