Discussion Week 8 _Assessing Musculoskeletal Pain

Instructions:

· Respond to your colleague who was assigned a different case study than yours.

· 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.

**minimum of three (3) scholarly references are required for each reply cited within the body of the reply & at the end**

Reply # 1

Episodic/Focused SOAP Note: Ankle Pain

Patient Information:

A.J., 46 years old, F, Wht

S.

CC: “Ankle pain”

HPI: AJ is a pleasant, 46-year-old, white female with a complaint of ankle pain. She reports pain in both of her ankles, but the pain in the right ankle is more severe. She was playing soccer over the weekend and heard a “pop”.  She is able to bear weight on both ankles but is uncomfortable.  She reports the pain in her left ankle as a 3 and the pain in her right ankle as a 9 on a scale to 1-10. She reports the pain as an aching and throbbing sensation. She reports temporary relief with ice and elevation; however, the pain is aggravated when she walks or touches it. She has not taken any over-the-counter medications for the ankle pain. She is more concerned about the constant pain in her right ankle. She denies having fevers, nausea, and vomiting.

Current Medications:

 Multivitamin Tablet Once Daily (last dose this morning)

Ibuprofen 400mg Every 6 Hours as needed for pain (last dose two weeks ago)

Allergies: No Known Allergies

PMHx: Influenza Vaccine (October 2021) Soc Hx: AJ is a soccer teacher at her community recreational center for middle school girls. She denies alcohol use, and never smoked. She denies use of marijuana or illicit drugs. She maintains a healthy lifestyle by exercising 5 days a week: alternating riding her bicycle and swimming. She is married and has 15-year-old twin daughters. She has a strong support system consisting of her family and her next-door neighbors.  

Fam Hx: Mother is alive age 78, Hx: Osteoarthritis, Gout. Father deceased at age 56 from motor vehicle accident, had no medical history or musculoskeletal disorders. Grandparents’ medical history not known. Brother, age 35, no medical history. Daughters, identical twins aged 15 diagnosed with asthma at age 5.

ROS:

GENERAL:  No weight loss, fever, chills, weakness, or fatigue

SKIN: Skin intact. No tenting. No rashes. No lesions. No discoloration. Swelling in right ankle.  

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

RESPIRATORY:  No shortness of breath, cough, or sputum.

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

MUSCULOSKELETAL:  Positive pain in right and left ankles. Tenderness of right ankle. No knee pains. No back pain. No muscle pains. No crepitus in joints.

HEMATOLOGIC:  No anemia, bleeding, or bruising.

PSYCHIATRIC:  No depression or anxiety.

O.

Physical exam: AJ is alert and oriented to person, place, time, and situation. She is sitting upright, full ROM in arms, legs, and hip. Palpable posterior tibial pulse 2+ bilaterally. Palpable dorsalis pedis pulse 2+ bilaterally. No crepitus in joints. Positive tenderness upon palpitation in right ankle. Swelling in right ankle without skin discoloration. Full range of motion in right ankle and left ankle without grating, popping, or clicking sounds. Positive for pain with dorsiflexion, inversion, eversion, and plantar flexion in right ankle. The right and left feet are aligned with the tabias. No redness or warmth present on ankles, metatarsals, or phalanges. She has an unsteady gait due to limping on her right foot.  

Diagnostic results:

X-Ray: An x-ray film analysis helps clinicians detect if there are any changes in joint spaces or if there are any fractures (Shuqiao et al., 2021). Gomes et al. (2020) stated that “the Ottawa Ankle Rules state that ankle radiographs are required if the patient experiences malleolar pain and bone tenderness at the posterior distal fibula/ tip of lateral malleolus, posterior distal tibia/tip of medial malleolus or an inability to weight bear for four steps both immediately and in the emergency department” (p.2). AJ’s injury fits within the parameters of this guideline. Sprains and disruption of ligaments are usually caused from an inversion injury (Gomes et al., 2020). Ankle fractures are typically associated with sporting injuries (Gomes et al., 2020). Acute ankle injuries are typically diagnosed using subjective data, objective physical examination, and radiographic imaging (Gomes et al., 2020).

Weight Bearing CT and MRI: A weight bearing CT scan provides an accurate picture of joint alignment in foot and ankle injuries (Krähenbühl et al., 2019). Both CT and MRI imaging are accurate for detecting ligamentous injury. AJ complains of pain with weight bearing. This radiographic diagnostic tool would help assess for possible abnormalities in her ligaments. Ferràs-Tarragó et al. (2020) stated that CT and MRI imaging have been proven better diagnostic tools than x-ray imaging to help clinicians differentiate tissue injury from a fracture in ankle injuries.

A .

Differential Diagnoses

1. Ankle Sprain

2. Talofibular Ligament Injury

3. Achilles Tendon Injury: Ferreira et al. (2020) stated that the mechanism behind 85% of ankle sprains are inversion and adduction with a plantarflexed foot. The anterior talofibular ligament is the most commonly affected ligament in ankle injuries (Ferreira et al., 2020). The calcaneofibular ligament and the posterior talofibular ligament can also be affected in ankle injuries; however, the talofibular ligament is the weakest lateral ligament (Ferreira et al., 2020). In ankle sprains tears and or injury can occur to the ligaments or tendons of the foot, such as the Achilles tendon, but injury is not isolated to ligaments (Ferreira et al., 2020). Bone bruising and cartilage damage can also occur (Ferreira et al., 2020). AJ may have a sprained ankle with injury to her ligaments or tendons.

4. Ankle Fracture: “Ankle torque fractures are mainly located in the fibula, tibia, fifth metatarsal, cuboid, navicular, and other less frequent foot bones, with the fibula being the most frequently affected” (Ferràs-Tarragó et al., 2020, p. 801). Ankle torque related fractures account for 50% of all fractures produced while playing sports (Ferràs-Tarragó et al., 2020). Since AJ heard a popping sound and acquired her ankle injury while playing soccer, it is possible that she developed a fracture from the impact between her ankle and the ball or impact from another player’s kick.  

5. Rheumatoid Arthritis: Rheumatoid arthritis (RA) is a chronic inflammatory disease that affects the synovial fluid of the joints causing pain and irreversible joint deformities (Enache et al., 2019). AJ complains of ankle pain in both ankles. With RA pain is felt bilaterally in the joints such as the hands, knees, ankles, or feet (Enache et al., 2019).

References:

Enache, L., Popescu, C. C., Micu, M., Cojocaru, A., Suta, V.-C., Suta, M., & Codreanu, C. (2019). Ankle involvement in rheumatoid arthritis - a comparison of inflammatory signs on musculoskeletal ultrasound and magnetic resonance imaging. Medical Ultrasonography, 21(3), 265–272. https://doi-org.ezp.waldenulibrary.org/10.11152/mu-2038

Ferràs-Tarragó, J., Antequera-Cano, J. M., Català-de-las-Marinas, J., Jordà-Gómez, P., & Aroca-Navarro, J. E. (2020). Ankle torque-related fractures and its echo-fast diagnosis protocol. European Journal of Trauma & Emergency Surgery, 46(4), 801–805. https://doi-org.ezp.waldenulibrary.org/10.1007/s00068-018-01069-y

Ferreira, J. N., Vide, J., Mendes, D., Protásio, J., Viegas, R., & Sousa, M. R. (2020). Prognostic factors in ankle sprains: a review. EFORT Open Reviews, 5(6), 334–338. https://doi-org.ezp.waldenulibrary.org/10.1302/2058-5241.5.200019

Gomes, Y.E., Chau, M., Banwell, H.A., Davies, J., & Causby, R.S. (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.ezp.waldenulibrary.org/10.7717/peerj.10152

Krähenbühl, N., Bailey, T. L., Weinberg, M. W., Davidson, N. P., Saltzman, C. L., Barg, A., Hintermann, B., Presson, A. P., Allen, C. M., & Henninger, H. B. (2019). Impact of Torque on Assessment of Syndesmotic Injuries Using Weightbearing Computed Tomography Scans. Foot & Ankle International, 40(6), 710–719.

Shuqiao Meng, Wenxia Tong, & Shanshan Han. (2021). Application of X-ray image measurement in the early diagnosis of sports injury of ankle ligament. Pakistan Journal of Medical Sciences, 37, 1580–1584. https://doi-org.ezp.waldenulibrary.org/10.12669/pjms.37.6-WIT.4841