ADV HEALTH ASSESSMENT

Case 2: Ankle Pain

Episodic/Focused SOAP Note

 

Patient Information:

46 y/o female

S.

CC (chief complaint) "Pain in both ankles, but my right ankle hurts more than the left”.

HPI: The patient is a 46-year-old female who comes into the clinic with complaints of bilateral ankle pain. The patient is however more concerned about her right ankle. The patient reports she was playing soccer over the weekend and heard a "pop." She is able to bear weight, but it is uncomfortable. The patient reports pain to the left ankle is 4/10 and pain to right ankle is 10/10. The patient reports pain to the bilateral ankle began 11 months ago after a motorbike accident that killed her husband. Patient reports the Tramadol prescribed three months ago by her PCP has been "helping somehow", but the pain to the right ankle is "unbearable"

Current Medications:

1. Bayer Multivitamin 1 tab daily

1. Caltrate 600+D plus 2 tabs PO daily

1. Metoprolol tartrate Po 1 tab daily

1. Tramadol 50mg PO 1 tab Q6 hours as needed

1. Effexor 75mg PO 1 tab daily.

Allergies:

1. Latex(hives)

1. Cipro(facial swelling)

PMHx: Hypertension; Vitamin D deficiency; depression

PSHx: C-section x2

Sexual/reproductive history: Heterosexual, a widow, has 2 daughters, just started dating a few days ago, not sexually active

Social history: Lives with her 2 daughters in a 2 story family home, has smoke and carbon monoxide detectors, drives and uses seatbelt all the time, car equipped with Bluetooth, denies using a cell phone while driving, rides a bicycle in the park 3x a week, denies wearing a helmet; drinks 2 -3 glasses of wine a week; denies smoking; denies illicit drugs, works an average of 36 hours a week as a teacher; volunteers to teach soccer in her neighborhood; teaches Sunday school on Sundays.

Immunization history: tetanus booster 6 months ago, flu shot (October 2019)

Family history: Mother: hypertension, Diabetes type II; Father: Hypertension, Lung cancer (deceased 14 years ago); sister: CAD, CVA; brother: hypertension; paternal grandfather: (deceased) hypertension, MI; paternal grandmother: (deceased) ESRD, diabetes type II, hypertension; maternal grandfather: prostate cancer, DM2, osteoporosis; maternal grandmother: COPD, hypertension, Parkinson's disease, dementia.

ROS:

GENERAL: A Pleasant appearing AA female in mild distress; appropriately dressed; speech is clear and logical; negative for fever, chills

HEENT:

Nose: symmetrical, no drainage, no nasal congestion, denies loss of smell

Eyes:  No visual loss, blurred vision, double vision, or yellow sclerae.

Ears: No hearing loss, no tinnitus, no drainage.

Throat and mouth: Denies difficulty chewing or swallowing, no dental caries, no erythema

SKIN: no rashes or itching noted; scar to lower abdomen

CARDIOVASCULAR:  Denies chest pain, or chest discomfort. No history of arrhythmia. No palpitations or edema. No cyanosis, clubbing, noted.

RESPIRATORY:  Denies shortness of breath; denies cough, and/or sputum. Lungs clear to auscultation

GASTROINTESTINAL: Abdominal sound present x4 quadrants, no changes in bowel habits; no abdominal pain; no palpated mass.

GENITOURINARY:  Denies dysuria, frequency. Last Pap smear 3 months ago; menstrual period irregular, last menstrual period on 05/26/2020.

NEURO: denies syncope, headache, paralysis, ataxia, numbness, or tingling in the extremities.

MUSCULOSKELETAL:  Bilateral ankle pain, right ankle swelling, denies stiffness.

HEMATOLOGIC:  No anemia, bleeding, or bruising.

LYMPHATICS:  No enlarged nodes. No history of splenectomy.

PSYCHIATRIC:  History of depression, on Effexor 75mg PO daily; reports occasional insomnia.

ENDOCRINOLOGIC:  Denies polyuria or polydipsia; denies cold or heat intolerance.

Physical exam:

VS: BP 158/84; P 94; R 18; T 98.0 oral; 02 100% RA Wt 156 lbs; Ht 66”

General: Appears clean, cooperative, in mild distress

HEENT: Normocephalic, PERRLA. Mucosae moist. No masses. Normal thyroid. Last eye exam 1 year ago. Last dental exam 4 months ago Chest/Lungs: Symmetrical; clear to auscultation, no rales, rhonchi, rubs

Cardiovascular: S1 & S2 present with no murmurs, RRR. No cyanosis. RLE edema +1; Pulses +2 in BLE

CNS: Alert, oriented; able to recall information; speech appropriate. Normal gait. Neuro: 2-12 grossly intact. Musculoskeletal: Strength 5/5 BUE, LLE 4/5, RLE unable to assess due to pain. Gait unable to assess due to BLE pain

Sensation: pain to bilateral ankles. DTR 2+.

Skin: Warm, intact, erythema, ecchymosis to Right lateral ankle

Diagnostic results:

The Ottawa ankle rules: The Ottawa ankle rules (OAR) are clinical decision guidelines used to identify whether patients with ankle injuries need to undergo radiography (Wang et al., 2013). This measure has been applied to reduce redundant radiographs and expenses. The OAR has proven to be a highly sensitive and modestly specific test for fractures associated with ankle injuries (Wang et al., 2013). There must be pain in the malleolar zone and one of the following: bone tenderness along the distal 6 cm 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 inability to bear weight for four steps both immediately after the injury and in the emergency department (Ball et al., 2017, p. 546).

Anterior drawer test: The clinician performs the test by manually applying an anteriorly directed force at the calcaneus or a backward push on the tibia and attempting to discern pathological talocrural joint laxity from normal physiological laxity (Croy et al., 2013). This test is used to routinely examine talocrural joint integrity to identify the severity of anterior talocrural joint laxity in the acute setting(Croy et al., 2013).

X-ray of right ankle standard series: Radiographic examinations of the ankle are important in the clinical management of ankle injuries in hospital emergency departments (Eastgate et al., 2014, Para 1). Patients who are classified as positive by the OAR, are considered to require a series of standard ankle radiographs to confirm the diagnosis (Wang et al., 2013).

25-hydroxy vitamin D: Fragility fractures may result from chronic vitamin D deficiency leading to osteoporosis (Sizar, Khare, Goyal, Bansal, & Gigler, 2020). 

Bone density test: Fragility fractures may result from chronic vitamin D deficiency leading to osteoporosis (Sizar, Khare, Goyal, Bansal, & Gigler, 2020). 

Differential Diagnoses

Lateral ligament complex injury: ankle sprains involve an injury to the ATFL and CFL and are the most common reason for missed athletic participation (Macknet & Weatherford, 2020). Symptoms pain with weight-bearing (may or may not be able to bear weight), swelling and ecchymosis, recurrent instability, catching or popping sensation may occur following recurrent sprains(Macknet & Weatherford, 2020). Ecchymosis and swelling noted to right lateral ankle, patient reports 'pop' sensation at the time of injury. Pain to right ankle with weight-bearing

Stress fractures to the distal fibula or cuboid bone: On physical examination, there is the hallmark localized point tenderness on the lateral foot, especially in the area of the cuboid bone. There may also be some mild erythema and subtle soft tissue swelling over the lateral foot area(Lau & Dreyer, 2020). Soft tissue swelling and erythema noted to right lateral ankle

Ankle sprain: Athletes and nonathletes share this similar injury most often as a result of soft tissue injury with symptoms that include pain, swelling, bruising, and damage ("Soft Tissue Injury", n.d.)

Achilles tendon rupture: Despite being the strongest and thickest tendon in the body, the Achilles tendon is the most common to rupture (Egger & Berkowitz, 2017). Achilles tendon ruptures most commonly occur in a healthy, active, young- to middle-aged population(Egger & Berkowitz, 2017). Immediate pain is present but gradually dissipates, leaving a patient to complain of difficulty with plantar flexion, weight-bearing, or a limp (Egger & Berkowitz, 2017). The patient is 46 years old, fairly healthy, active, reports immediate pain to the right ankle while playing soccer, able to bear weight but uncomfortable.

Tarsal Navicular Fracture: Fractures of the tarsal navicular bone are most commonly the result of either traumatic injury or undue stress (Gheewala, Arain, & Rosenbaum, 2019). Patients who have endured a navicular body fracture present with a profound degree of swelling on the dorsal and medial aspects of the foot, all of which is due to the mechanism of the injury and disruption of the medial column of the foot (Gheewala, Arain, & Rosenbaum, 2019).

The practitioner should also investigate menstrual history in females, nutrition (to include calcium and vitamin D intake), medications, footwear, and special equipment used (especially in a sport such as a triathlon) (Lau & Dreyer, 2020) 

References

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2017). Seidel's guide to physical examination - E-book: An interprofessional approach. Elsevier Health Sciences.

Croy, T., Koppenhaver, S., Saliba, S., & Hertel, J. (2013). Anterior Talocrural joint laxity: Diagnostic accuracy of the anterior drawer test of the ankle. Journal of Orthopaedic & Sports Physical Therapy, 43(12), 911-919. https://doi.org/10.2519/jospt.2013.4679

Eastgate, P., Davidson, R., & McPhail, S. M. (2014). Radiographic imaging for traumatic ankle injuries: A demand profile and investigation of radiological reporting timeframes from an Australian tertiary facility. Journal of Foot and Ankle Research, 7(1). https://doi.org/10.1186/1757-1146-7-25

Egger, A. C., & Berkowitz, M. J. (2017). Achilles tendon injuries. Current reviews in musculoskeletal medicine, 10(1), 72–80. https://doi.org/10.1007/s12178-017-9386-7

Lau, H., & Dreyer, M. A. (2020, July 07). Cuboid Stress Fractures. Retrieved July 22, 2020, from https://www.ncbi.nlm.nih.gov/books/NBK542250/

Gheewala, R., Arain, A., & Rosenbaum, A. J. (2019, June 01). Tarsal Navicular Fractures. Retrieved July 22, 2020, from https://www.ncbi.nlm.nih.gov/books/NBK542221/

Macknet, D., & Weatherford, B. (n.d.). Ankle Sprain. Retrieved July 22, 2020, from https://www.orthobullets.com/foot-and-ankle/7028/ankle-sprain

Soft-Tissue Injuries. (n.d.). Retrieved July 22, 2020, from https://www.hopkinsmedicine.org/health/conditions-and-diseases/softtissue-injuries

Wang, X., Chang, S., Yu, G., & Rao, Z. (2013). Clinical value of the Ottawa ankle rules for diagnosis of fractures in acute ankle injuries. PLoS ONE, 8(4), e63228. https://doi.org/10.1371/journal.pone.0063228