respond

Respond to THE two PSOT BELWO THREE REFFERENCES BENEATH EACH POST. Analyze the possible conditions from your colleagues' differential diagnoses. Determine which of the conditions you would reject and why. Identify the most likely condition, and justify your reasoning.

POST 1

Patient: Jane Doe                           Gender: Female                                      Age: 46

S. CC: “Bilateral Ankle Pain”  HPI: The patient is a 46-year-old female who has a complaint of bilateral ankle pain that started over the weekend after she heard a “pop” while she was playing soccer.  Patient’s primarily concerned about pain in the right ankle.  Patient is able to ambulate in office so she can bear weight but appears to do so with some discomfort.  PMH: No past medical history noted. FH: None reported. SH : Plays soccer occasionally ROS    General--Positive for bilateral lower extremity discomfort since the weekend.  Most likely in overall decent health since she is playing soccer on the weekends.

Musculoskeletal- Positive for pain to bilateral lower extremity.  Pain to right ankle is the primary focus.

Skin—Check for redness or swelling to the affected extremity

O.

VS: Not available

General--Pt appears to have good overall health, posture and can ambulate with some discomfort. The patient seems to be in some discomfort with weight bearing and has an intact level of cognition. 

Musculoskeletal- Reports primary pain and discomfort to right ankle.  Patient reports less pain to left ankle and is weight bearing with ambulation.

Neurological- Appears alert and oriented

Skin- Must inspect for swelling or discoloration.

Diagnostic Testing: 

Range of motion exam- To test the patients active and passive range of motion to test joint and muscle groups.  Could indicate abnormalities, and areas of pain and tenderness.  Use of goniometer to measure joint range of motion and if the disease is outside the joint or extra-articular, passive motion may be painless, whereas active motion produces pain (Dains, Baumann, & Scheibel, 2016).

Multi view Ankle XR- will provide imaging of the ankle to look for abnormalities such as deviation, fractures, deformities or abnormalities such as in the “Boehler’s Angle” (Boehler's angle is defined as the angle formed by two lines: one drawn tangent to the superior aspect of the calcaneus and the second drawn tangent to the inferior aspect of the calcaneus. The angle normally ranges from 20 to 40 degrees (University of Virginia, n.d.). 

Lower extremity CT or MRI—To visualize the soft tissue and may be required to fully assess the extent of soft tissue damage (University of Virginia, n.d.)

A.

Differential Diagnosis: 

1) Torn Ligament or tendon-Based on the diagnostic x-rays, the patients report of hearing a “pop”, her activity at the time of the injury and the fact that she still had the ability to bear weight on the injury is it very likely that the patient is suffering from a torn ligament.  This is evidenced by x-rays appearing normal as ligament damage without fracture, injury often cannot be seen on plain film but is usually demonstrated as soft tissue swelling over the injury site (University of Virginia, n.d.).  There is also the consideration and many patients often report that they hear a “pop” sound when a tendons snap.  Tendons become less elastic. This results in a reduction of total muscle mass, tone, and strength (Ball, Dains, Flynn, Solomon, & Stewart, 2015, p. 508).

2) Sprain- Given that the patient injured herself but is still able to ambulate (even though there is comfort) there is a very good chance that she has suffered a soft tissue injury such as a sprain. Sprains cause minimal to moderate pain, increasing 1 to 2 days after the trauma when the inflammatory process begins (Dains et al., 2016, p. 257).  Sprain presentation may range from mild pain and swelling to severe pain and swelling with an inability to walk (University of Virginia, n.d.)  This is evidenced x-rays appearing normal, continue pained and discomfort, and the patient being able to ambulate.

3) Dislocation- Dislocations are less common than fractures but usually occur in conjunction with fractures and is defined as a complete separation of the contact between two bones in a joint.  It usually occurs in the setting of acute trauma and results in the inability to use the joint as usual (Ball et al., 2015).  Not all dislocations remain dislocated but may often “pop” back in leaving the patient with pain, swelling and loss of range or motion to the affected extremity.  This condition is evidenced by the patients report of hearing a “pop” from her activity at the time and could have been her ankle dislocating and going back in.  This is also evidenced by the fact that she still had the ability to bear weight and will be evaluated by diagnostic x-rays, CT or MRI

4) Undiagnosed fracture- Fractures can be partial or complete break in the continuity of a bone

from trauma direct, indirect, twisting or crushing such as the patient’s report of playing soccer and can be described by patients as feeling a pop or snap with injury (Ball et al., 2015).  With a stress fracture, there may be mild swelling and tenderness and pain with weight bearing (Dains et al., 2016, p. 257).  This is evidenced by the patient indeed report that she indeed heard a pop, has pain and discomfort primarily to the right ankle (which could be the fracture) and that fact that she is weight bearing point towards and incomplete fracture.  Some fractures are not easily diagnosed via x-ray and can become more pronounced with time.  

 Primary Diagnosis/Presumptive Diagnosis: It is the opinion of this provider that nurse that the most likely diagnosis in this case would be an undiagnosed incomplete ankle stress fracture that is not immediately evident in the x-ray. This is the most likely diagnosis as the majority of the patient’s symptoms of hearing a “pop”, her activity at the time of the injury, and the fact that she still had the ability to bear weight on the injury.

References

Ball, J., Dains, J., Flynn, J., Solomon, B., & Stewart, R. (2015). Seidel’s guide to physical examination (8th ed.). St. Louis, MO: Elsevier Mosby.

Dains, J., Baumann, L., & Scheibel, P. (2016). Advanced health assessment & clinical diagnosis in primary care (5th ed.). St. Louis, MO: Elsevier Mosby.

Huether, S. E., & McCance, K. L. (2017). Understanding pathophysiology  (6th ed.). St. Louis, MO: Mosby.

University of Virginia. (n.d.). Introduction to radiology: A online interactive tutorial. Retrieved from https://www.med-ed.virginia.edu/courses/rad/ext/8ankle/10gc.html

POST 2

Initial Discussion Post - Week 8

COLLAPSE

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Episodic/Focused SOAP Note Template

Patient Information: 

RL, 42 y/o Caucasian male, complains of lower back pain that started one month ago 

S.

CC: “Lower back pain”

HPI:  The patient is a 42 y/o Caucasian male complaining of lower back pain that radiates down his left leg. This pain began approximately one month ago. He describes the pain as “shooting” and is rated 6/10 in severity. The patient has not taken any medications for the back pain and states his pain is worse after exercise and slightly improved with rest. The patient also c/o numbness and tingling to the LLE. 

Current Medications:  No current home medications. 

Allergies:  NKA

PMHx: UTD on immunizations. Covid Vaccine #1 4/7/21 Pfizer, Covid Vaccine #2 4/21/21 Pfizer. Denies any other medical history.  Soc Hx:  Patient is employed as a welder. Denies tobacco use. Occasional ETOH use, 1 beer weekly. 

Fam Hx:  

Mother: HTN, HLD

Father: colon cancer 

Brother: Asthma 

Maternal Grandmother: died age 78 of “natural causes” 

Maternal Grandfather: HTN

Paternal Grandmother: died age 63 of breast cancer

Paternal Grandfather: died age 72 of MI 

ROS:  

GENERAL:  Denies weight loss, fever, chills, weakness, or fatigue.

HEENT:  Eyes: Denies visual loss, blurred vision, double vision or yellow sclerae. Ears, Nose, Throat:  Denies hearing loss, sneezing, congestion, runny nose, or sore throat.

SKIN:  Denies rash or itching.

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

RESPIRATORY:  Denies shortness of breath, cough, or sputum.

GASTROINTESTINAL:  Denies anorexia, nausea, vomiting or diarrhea. No abdominal pain or blood.

GENITOURINARY:  Denies burning on urination.  

NEUROLOGICAL:  Denies headache, dizziness, syncope, paralysis. No change in bowel or bladder control. Positive numbness and tingling LLE. 

MUSCULOSKELETAL:  Lower back pain radiating to left leg.  

HEMATOLOGIC:  Denies anemia, bleeding, or bruising.

LYMPHATICS:  Denies enlarged nodes. No history of splenectomy.

PSYCHIATRIC:  Denies history of depression or anxiety.

ENDOCRINOLOGIC:  Denies reports of sweating, cold or heat intolerance. No polyuria or polydipsia.

ALLERGIES:  Denies history of asthma, hives, eczema, or rhinitis.

O.

VS.   BP 132/74, P 76, RR 18, T 98.6 F, SpO2 99% on RA, Wt. 187 lbs., Ht. 5’11 

Physical exam: 

General: No acute distress. 

Cardiovascular:   Heart rate regular. No edema. No murmur. 

Respiratory: Lung sounds clear to auscultation. No SOB observed. 

Musculoskeletal: Steady gait.  Positive pain with straight leg raise. 

Neurological: Numbness and tingling LLE. 

Diagnostic results:  Straight leg raise, Lumbosacral x-ray, EMG (Cleveland Clinic, 2021). 

A .

Differential Diagnoses  

1. Sciatica: Sciatica refers to pain that radiates from the lower back down the back of the thigh and leg. This occurs in the distribution of the sciatic nerve (Shoemaker, 2018). 

2. Lumbosacral Radiculopathy: This is herniation of a lumbar disk that irritates the spinal nerve root (Ball et al., 2019). Symptoms can be brought on by heavy lifting or physical exertion and can include lower back pain that radiates down the leg (Ball et al., 2019). 

3. Bursitis of the hip: Bursitis can present as lower back pain that radiates down the lateral or posterior thigh (Shoemaker, 2018). 

4. Lumbar Stenosis: This is narrowing of the spinal canal (Ball et al., 2019). Pain begins in the buttocks/back and radiates down the legs (Ball et al., 2019). 

5. Piriformis syndrome: Though rare, this condition can cause pain in the distribution of the sciatic nerve due to either muscle hypertrophy or fibrosis involving the nerve roots (Shoemaker, 2018). 

References

Ball, J., Dains, J., Flynn, J., Solomon, B., Stewart, R. (2019). Seidel’s Guide to Physical Examination An Interprofessional Approach. (9th ed.). Elsevier.

Cleveland Clinic. (2021). Sciatica. July 20, 2021, https://my.clevelandclinic.org/health/diseases/12792-sciatica

 Shoemaker, R. (2018). Indications of Sciatica in a Physical Exam. July 20, 2021, https://www.hrphysician.com/indications-of-sciatica-in-a-physical-exam/

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