SOAP Note 2 Comprehensive SOAP Cardio/Respiratory

SOAP Note

Nicole Wertheim College of Nursing and Health Sciences - Florida International University

NG 6601L – Advanced Family Health Nursing Practice

Professor:

November 13th, 2023

Patient Age: 21-year-old male Patient

Ethnicity: African American

Clinical Setting: MSMC ED Blue Pod Patient

Status : ED patient New

Subjective Data

Chief Complaint

“Twisted Left ankle”

History of Present Illness

A 21-year-old African-American male presents to the emergency department complaining

of left ankle pain and the inability to bear weight on the left foot. Pt. states that he was playing

basketball yesterday and was “going in for a rebound when he landed on a teammate's foot,” and

his left ankle inverted. He describes the pain as dull and, throbbing,non- radiating and currently

states the pain is a 7/10. Pt. says the pain is intensified if the leg is in a dependent position or if he

attempts to bear weight. Pain is relieved with rest, ice, elevation, and Ibuprofen 600mg; the last

dose was taken before bed last night. Pt. denies any LOC, H/A, neck pain, sore throat, cough,

SOB, CP, abdominal pain, back pain, lower extremity weakness, swelling, dysuria, hematuria,

fever, chills, rashes or unintentional weight loss. Pt. states, “I am scared I may have fractured it,

and I want an X-ray; if it’s a sprain, my team has a physical therapist I can see.” No further

complaints at this time.

Past Medical History

Patient denies past medical history

Medications

Denies any medications, supplements, or vitamins. Pt. took OTC Ibuprofen x1

dose before bed last night with minimal relief for pain relief.

Past Surgical History

Denies any past surgical history

Allergies

NKDA

Health Promotion and Maintenance

The patient is fully vaccinated for COVID-19. He has not had the seasonal flu

vaccine and is scheduled for his annual physical with this primary care provider

next month (Dec, 2023). Pt. has had his vision checked one month ago (Oct, 2023)

and wears corrective lenses to read. Immunizations are up to date, STI

screening was performed two months ago (Sep, 2023), and safe sex practices were

discussed with the patient. The patient denies the use of alternative care practices

and states he is not religious, but his mother is a very devout Christian.

Family History

Patient mother – 42 yr old- Healthy, no medical conditions

Patient Younger Sister – 12 yr old- Healthy (seasonal allergies)

Grandmother- deceased (78), CVA

Grandfather- deceased (80) MVA

Social History

The patient lives with his mother. He is the youngest child at 21 years of age,

with one sibling, who is 12 years of age. He attends college, works part-time, and

plays competitive basketball. He follows a heart healthy diet. He works out 3-5

times per week, follows a high- protein, low carb diet, and denies alcohol, tobacco

and vape use, but reports smoking marijuana occasionally.

Marital status- Single

Parental status- no children

Work history- part- time job at a sneaker shop

Financial history- Insured

Diet- Heart healthy, high protein, low carb, x3 meals/day, well hydrated/well nourished.

Exercise- Frequency (3-5x/week) competitive basketball player.

Stress management- Sports, video games, dancing.

Sleep- 6-8 hours/night

Sexual history/orientation- Heterosexual male, sexually active (x1 partner), uses protection,

screened for STIs. “In the past twelve months, how many partners have you had?” (Two) “Do

you have vaginal sex, anal sex, oral sex, anal sex?” Engages in vaginal and oral sex and utilizes

condoms. Past history of STIs? No.

Living arrangement- Lives with mother and younger sister in a gated apartment complex.

Social support- Mother, sister, basketball team, and a good circle of friends.

Travel history- In-state travel, denies out-of-state travel for the past five years.

Functional Status

The patient is fully independent with ADLs.

Cultural Background

Individuals identifying as Black or African American make up 12.5% of individuals

within the United States; when in combination with other race groups, that percentage increases

to 15% (Larson, 2022). Regarding health, healthcare, and approach to patients, it is vital to

understand the basics of the following: marginalization, discrimination, racism, and lack of

access to care are visceral issues that affect black patients far more than white counterparts. As

healthcare providers, implicit bias, although an unconscious thought process affecting our

decision-making, can significantly affect patient outcomes, treatment, patient interaction,

therapeutic options, diagnoses, and all aspects of patient interaction (Larson,2022). Today's

presenting patient is a healthy black male, health conscious, providing an opportunity to build

rapport with healthcare providers and be further counseled regarding health screenings,

prevention, and maintenance. Early conversations regarding heart disease, hypertension, and

stroke will be beneficial in educating this patient regarding health equity and access to healthcare

screenings necessary to ensure good health. Blacks are two times more likely to pass away from

heart disease than white counterparts (Larson, 2022).

Review of Systems (Patient as Historian)

Constitutional: Patient denies chills, fatigue, excessive weight loss, or weight gain.

Head/face: Patient denies dizziness, headaches, or lightheadedness

Eyes: Patient denies any pain, redness, excessive tearing, double or blurred vision. The

patient utilizes glasses for computer use/video games/schoolwork. Last eye examination

one month ago (Oct 2023).

Ears: Patient denies ear pain, drainage, and ear ringing. Pt. has never had vertigo, ear

infections, or cerumen impactions.

Nose: Patient denies nasal stuffiness, discharge, or itching. No nosebleeds or sinus

trouble was reported.

Mouth/Throat/ Neck: Patient denies sore throat; no pain or stiffness in neck is reported.

Last dental examination: x1 yr ago with no issues reported: no mouth sores, voice

changes, or hoarseness.

Respiratory: Pt denies cough, SOB, wheezing, or painful breathing—no history of

asthma, no recent URI, or history of pneumonia.

Cardiac: No chest pain or discomfort, shortness of breath, or palpitations reported. No

swelling was reported. No sudden awakening from sleep, no difficulty breathing while

lying down. Past EKGs were reported to be normal. Yearly sports physical conducted for

competitive basketball.

GI: Pt. denies abdominal pain, indigestion, N/V/D, hematochezia, and changes in

appetite. States he has normal bowel movements with regularity.

Peripheral Vascular- Negative for leg cramps, varicose veins, calf swelling, redness or

tenderness.

GU: No dysuria or hematuria reported. No issues with bowel or bladder control were

reported. No penile discharge, scrotal swelling, or STI concern.

Musculoskeletal: Complaining of pain, tenderness, and lateral swelling to the LEFT

ankle with inability to bear weight. Decreased range of motion and bruising to the

LEFT ankle, no loss of sensation. Denies joint pain, stiffness, weakness, swelling, or

movement limitations to the right lower extremity, and no joint pain/stiffness/limitations

or loss of sensation to the upper extremities.

Skin/Integument: No rashes, lesions, or itching reported. The patient denies any skin

changes. Patient denies changes to hair or nails.

Psychiatric: No behavioral or emotional issues reported, no anxiety, depression or

suicidal ideations.

Neuro: No neurological symptoms reported. Pt. states no history of strokes, seizures,

numbness, tingling, mood changes, dizziness, vertigo, or fainting.

Endocrine: Denies any temperature intolerance, excessive sweating, no hormone

therapy, no complaints.

Hematologic/Lymphatic: No history of bleeding disorders or frequent infections,

abnormal bleeding, or bruising. No known allergies reported.

Allergic/Immunologic: no allergies, or immunologic issues to report.

Objective Data

Vital Signs

BP: Left Arm: 122/76

HR: 64

RR: 20

O2 Sat: 100% on room air

Temp: 98°F

Height: 6’2”

Weight: 180 lbs.

BMI: 23.11 (healthy)

Physical Examination

Constitutional: The patient appears his stated age, is well groomed, and is in no acute distress,

denies weight loss, night sweats or chills.

General: The patient is a 21-year-old male who appears his stated age, is well-appearing, and

has a well-nourished athletic build. No signs of pallor, cyanosis, or jaundice noted. He presented

to the ED and is seated in a semi-fowlers position. He is awake alert and oriented to person, time,

and place. No recent weight changes reported. Patient presents due to Left ankle pain x1 day after

a sports injury whilst playing basketball.

Head/face: Normocephalic and atraumatic. Facial expressions are appropriate. No abnormalities

noted to eyebrows, palpebral fissures, nasolabial folds, and sides of mouth. No weakness or

involuntary movements noted to facial muscles. No swelling noted. Pt. denies any facial trauma,

or pain.

Eyes: Pupils equal, round, and reactive to light. Extraocular movements are intact. The eyeballs

look moist and glossy; they are aligned normally with no protrusion or sunken appearance. No

loss of vision. Pt utilizes corrective lenses. No history of eye surgery, eye pain, photophobia,

diplopia, spots or floaters.

Ears: The ears are equal size bilaterally with no swelling or thickening. Skin is intact with no

lumps or lesions. Pinna and tragus are firm with no pain during movement. Palpation to mastoid

process is painless. No swelling, redness or discharge noted to external auditory meatus. No

redness swelling, lesions, foreign bodies or discharge noted to external canal. The tympanic

membrane is intact, shiny and translucent, no discoloration noted.

Nose: The nose is symmetric, midline proportionate to other facial features. No deformities,

asymmetry, inflammation, or skin lesions. Nostrils are patent. Nasal mucosa is a normal red

color with a smooth and moist surface. No excessive secretions, blood or purulent drainage

noted.

Mouth/Throat/ Neck: Lips are moist, no cracking or lesions noted. Oral mucosa moist, no

thrush or lesions noted. Teeth appear straight, evenly spaced, free of decay. The jaw is properly

aligned. The tongue is pink and even. Neck is supple, motion is smooth and controlled. Trachea

is midline. No drooling,or pooling of saliva noted. No cervical lymphadenopathy noted, no

posterior lymphadenopathy noted, no masses. Thyroid not palpable, no bruits. Carotid pulses 2+

and equal bilaterally.

Respiratory: Chest expansion symmetric. Breath sounds are clear to auscultation bilaterally, no

rales, rhonchi, or adventitious breath sounds. Respiratory rate is normal, and respirations are

relaxed and even.

Cardiac: S1 and S2 are normal, not diminished or accentuated, no extra sounds, no murmurs.

Capillary refill is brisk <2 seconds. Apical impulse at 5th intercostal space, left midclavicular

line. No heave or thrill. Regular rate and rhythm with no murmurs. Pt. is very athletic, HR stable

between 50-65 bpm.

GI: Flat, symmetric with no apparent masses. Skin smooth with no striae, scars, or lesions.

Bowel sounds present, no bruits. Tympany to percussion in all 4 quadrants. Abdomen soft to

palpation, no guarding, no rebound, no CVA tenderness, no organomegaly, no masses, no

tenderness. LBM this morning.

GU: No abnormalities or lesions noted.

Musculoskeletal: Unable to tandem walk due to Left ankle pain, presents with limping gait.

LEFT ANKLE: Limited ROM, tenderness to the lateral malleolus, mild swelling and

ecchymosis noted. Anterior Drawer tests positive for pain indicating pain at the Anterior

Talo-Fibular Ligament. Pt. denies tenderness to the tibia and fibula confirmed with the squeeze

test. No abnormalities to the left foot or toes, no swelling or tenderness or bruising noted at the

base of the fifth metatarsal. Pain is localized solely at the lateral malleolus. Patient is able to bare

weight fully on right foot. Joints and muscles symmetric; no swelling, masses, or deformity

noted to right lower extremity; Muscle strength—able to maintain flexion against resistance and

without tenderness. normal spinal curvature. No tenderness to palpation of right lower extremity

or upper extremities. DPA and PTA 2+ bilaterally.

Skin/Integument: Skin is brown/black, warm to touch, and dry, with no rashes or lesions noted.

Skin turgor is within normal limits, no clubbing or deformities, nail beds pink with prompt

capillary refill <2 seconds.

Psychiatric: Patient is calm with no acute mental status changes.

Neuro: Cranial nerves II-XII grossly intact. No focal neurological deficits or changes

appreciated. light touch, vibration intact.

Mental Status: Age-appropriate behavior and interaction observed.

Motor Strength: Gross and fine motor skills appear normal. 5/5, +5 , DTR 2+ throughout.

Sensory: No sensory abnormalities observed.

Hematologic/Lymphatic/Immunologic: No abnormalities noted on exam.

Assessment

Primary Diagnosis – Left Ankle Sprain/ Unspecified Ligament Injury of the Left Ankle

(S.93.402.A)

** Based on physical exam and inversion injury, strong suspicion of Talo-Fibular Ligament involvement.

Differential Diagnosis

Ankle Fracture (S82)

Stress Fracture (M84.372A)

Tendon Dislocation or Rupture (S93.05XA)

Ligamentous Laxity syndrome/fathers medical history unknown) (M24.2)

Risk Factors

Competitive basketball player, low top sneakers worn the day of injury.

Plan

Diagnostics: Based on the Ottawa Ankle Rule, this patient presents with left ankle lateral

malleolar pain, with bony tenderness to the tip of the lateral malleolus and an inability to bare

weight or take four steps after the injury and within the emergency department. Given the patients

presentation, an ankle x-ray is indicated (Hwang,2023). The clinical pearl of Ottawa

Rules are the exclusion of fifth metatarsal or foot pain. This patient does not have fifth metatarsal

or foot pain, indicating that a Left ankle 3 view x-ray is appropriate in this case presentation.

Our patients x-ray was negative, physical exam was indicative of a tendon injury. Requiring

further evaluation for sprain grading and treatment.

Pharmacologic management: Ibuprofen 600mg, every 8 hours as needed for pain OR,

Acetaminophen 650 mg every 4-6 hours for pain , there has been no research to show superiority

over a particular NSAID. The patient is a healthy male and has selected Ibuprofen prior to arrival

(Maughan & Jackson, 2023). Ibuprofen 600mg given in the ED prior to x-ray, ICE pack applied

in ED.

Non-Pharmacologic management: Air Cast application, crutches, RICE : Rest, Ice,

Compression, and Elevation.

• Protection and compression with the Air Cast

• Rest with limited movement and no weight bearing and use of crutches

• Cryotherapy, 20 minutes every 2-3 hours while awake for the first 72 hours

• Elevation- to alleviate swelling, above the level of the heart.

Patient Education:

1. Rest ankle, ensure proper use of crutches, and follow RICE protocol with barrier between

skin and cryotherapy (Maughan & Jackson, 2023).

2. Given competitive sports involvement follow up with orthopedic and physical therapy

after orthopedic clearance. It is shown that patients that seek physical therapy for ankle

sprain recovery are less likely to have recurrent or chronic ankle sprains (Duwairi, 2023).

Referrals: Orthopedic Surgeon and Physical Therapy

Follow up: Follow up with PCP or return to the ED if worsening or no improvement within 7

days.

Analysis

Within this case, a very healthy and athletic 21-year-old male presented with left ankle

pain, and stated that he had an inversion injury the day prior whilst playing basketball. He denied

any significant past medical history, surgical history or social history significant to this case. The

patient denied any previous sports injuries or ankle/foot/leg injuries previously. Subjectively he

reported classic signs and symptoms of a Grade 1-2 ankle sprain such as moderate pain,

swelling, tenderness and ecchymosis with moderate joint instability and restriction of range of

motion and inability to bare weight .Lateral sprains due to inversion injuries are responsible for

70-90% of all sprains (Maughan & Jackson, 2023).

On physical exam, he presents with lateral swelling over the malleolus, bony tenderness

to the tip of the lateral malleolus and an inability to bare weight or take four steps after the injury

and within the emergency department. Ecchymosis over the malleolus, and a non-tender tibia,

fibula, and left foot. The patient had a positive anterior drawer test, and a limping gait on arrival.

Initial goals for this patient are to control pain, reduce swelling, and maintain range of

motion before gradually introducing exercise (Maughan & Jackson, 2023). PRICE: an acronym

similar to RICE just adding protection is important in the acute stages and is essential when

including the lateral malleolus for the first three days after injury. If the sprain is a Grade 1 or 2,

range of motion exercises such as plantar flexion, dorsiflexion, and foot circles or the alphabet

can be achieved passively after the acute phase has subsided (Duwairi, 2023). Functional

rehabilitation has been shown to be far superior when compared to complete immobilization,

thus early light activity, and physical therapy consults are important for patients (Maughan &

Jackson, 2023). Ironically in any sprain grade immobilization was not completely preferred.

NSAIDS, should be given as needed for pain and non-pharmacological options such as

PRICE should be utilized to ensure protection, rest, ice, compression and elevation are achieved

in the acute phase. The patient is a competitive athlete and should be referred and evaluated by

an orthopedic surgeon and physical therapist, and be sure to return to the ED or PCP should

symptoms not improve. Very interestingly in cadaver study of human anterior talofibular

ligaments, 50% of humans have a single banded ligament, where 50% have a double banded

ligament. Making the strength of the ligament stronger with double-banded ligaments (Sarcon et

al., 2019). The phrase “I am prone to ankle sprains”, is anatomically true. The Ottawa Rules help

practitioners make better decisions when treating ankle and knee injuries guiding our diagnostic

decisions. In this case, X-ray decisions with a 3-view x-ray (negative results), ice, compression,

rest and elevation, the patient was well managed.

References

Duwairi, M. Q. (2023). Acute ankle sprain. Saudi medical journal, 19(3), 329–331.

Hwang, C. (2023). Ottawa ankle rule. MDCALC.com. Retrieved 2023, from

https://www.mdcalc.com/calc/1670/ottawa-ankle-rule

Larson, J. (2022). Cultural Considerations in Working with Black and African American Youth.

Child and Adolescent Psychiatric Clinics of North America, 733–744.

Maughan, K. L., & Jackson, J. (2023). Ankle sprain in adults: Evaluation and diagnosis (M.

Gammons, F. G. O'Connor, & J. Grayzel, Eds.). UpToDate. Retrieved November 16,

2023, from https://www.uptodate.com/contents/ankle-sprain-in-adults-evaluation-and-

diagnosis?search=ankle%20sprain%26source=search_result&selectedTitle=1~53&usage

_type=default&display_rank=1

Sarcon, A. K., Heyrani, N., Giza, E., & Kreulen, C. (2019). Lateral ankle sprain and chronic

ankle instability. Foot & Ankle Orthopaedics, 4(2), 247301141984693.

https://doi.org/10.1177/2473011419846938