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NITIAL POST: Review of Case Study #2 Episodic/Focused SOAP Note Ankle Pain/Injury Patient Information: Initials: R.G. Age: 46 Sex: Female Race: African American

S. CC: Bilateral ankle pain, “I was playing soccer over the weekend, and heard my R ankle “pop”.

HPI: Patient, R.G. a 46-year-old A.A. female presenting to the clinic today complaining of bilateral ankle pain. She states she was playing soccer over the last weekend, 3 days ago, and heard a “pop” in her R ankle. She had been running for approximately 100 yards before this. She denies any fall or injury prior to this episode. She describes the pain as sharp and stabbing when bearing weight, and pain continues in a throbbing character when at rest. She states pain is worse at night and this is interrupting her sleep pattern. She can bear weight on the R foot, but it is painful. She states the pain is constant but is worse when standing, rating the pain 8/10 when bearing weight and 3/10 when resting and non-weight bearing, on a numeric pain scale. She states her R ankle is tender to palpation, and pain is not radiating. She states her L ankle pain is less severe at 2/10 at all times, on a numeric pain scale, despite activity. She states she took 200 mg Ibuprofen, but this was not effective. She denies any other associated symptoms like numbness and tingling.  Current Medications: No prescription medications, Women’s daily multivitamin taken once a day. Ibuprofen 200 mg tablet taken one time for R ankle pain. 

Allergies: Penicillin-puritis, strawberries-anaphylaxis, seasonal allergies to pollen-watery eyes, and no latex allergy noted. 

PMHx: Reports anxiety at times, no recent episodes, and no current treatment. Patient denies major illness or disease, surgeries, or hospitalizations. Immunizations up-to-date, last Tetanus 12/22/22, COVID vaccine 1/2/2021, and Influenza vaccine 11/2/2022. 

Soc Hx: R.G. is a single female with no children. She offers she is currently in the process of adopting a child from Russia. She lives in a single home which she owns. She works from home completing insurance claims via computer and works 8 hours a day. She lives alone. She reports she drinks alcoholic drinks weekly, usually 1-2 drinks at a time, she denies vaping, smoking, use of tobacco, use of recreational drugs, or illicit drugs, she denies any prior tobacco or illicit drug use. Her home has cameras along with a WIFI operated garage door and house doors so she can operate when she is not at home for safety. She indicates she always wears a seatbelt when driving her car. She states she does not text while driving. She denies sexual activity currently, last episode 5 years ago. She is not currently in a relationship and states her girlfriends provide the support she needs. She denies having a STI in the past and denies any past STI testing. Her last menstrual cycle in the last 28 days. She has been on a soccer league for the past 7 years. She plays soccer every weekend. She reports her living environment is safe and has working smoke detectors in the home along with a camera security system.  

Fam Hx: Mother, living 80-year-old, only medical history is Dementia and HTN. Father, died at 65-years-old from lung cancer. Paternal grandmother, died at 94-years-old after a long battle with lung cancer. Paternal grandfather died at 50-years-old in an MVC. Maternal grandmother, died at 82-years-old from unknown illness, family was not in contact. Maternal grandfather, died at 84-years-old from congestive heart failure. She does not have any siblings. No other pertinent family medical history.

ROS: GENERAL:  No weight loss, weight gain, fever, chills, weakness, or fatigue. SKIN:  No rash or itching. CARDIOVASCULAR:  No chest pain, chest pressure or chest discomfort. No palpitations or edema. RESPIRATORY:  No shortness of breath, cough, or sputum. NEUROLOGICAL:  No BLE numbness or tingling, headache, dizziness, syncope, recent falls, paralysis, or ataxia. No change in bowel or bladder control. MUSCULOSKELETAL:  Joint pain in bilateral ankles, increased pain, swelling, and redness to lateral aspect of R ankle. No back pain.  HEMATOLOGIC:  No anemia, or bleeding. Reports light purple bruising noted to R lateral aspect of R ankle.  PSYCHIATRIC:  No history of depression or anxiety. ENDOCRINOLOGIC:  No reports of sweating, cold or heat intolerance. No polyuria or polydipsia. ALLERGIES:  Penicillin-puritis, strawberries-anaphylaxis, seasonal allergies to pollen-watery eyes and rhinitis, and no latex allergy noted. No history of asthma, hives, or eczema.

O. VS: BP 138/72, HR 70, Resp 18, Temp 98.7 F, Sp02 97% RA, Ht. 5’8”, Wt. 185 lbs.  Physical exam:  GENERAL: Alert and oriented x3, appears to be her stated age, dressed appropriately for current weather, clean and well groomed, calm and cooperative.  CARDIOVASCULAR: S1 and S2 present, no advantageous heart sounds. No murmur, and tibial and pedal pulses present bilaterally +2.  RESPIRATORY: Lungs clear to auscultation, no congestion, rhonchi, or wheezing noted. Lung expansion equal bilaterally.  NEUROLOGICAL: Equal strength, equal sensation, no numbness or tingling, and decreased ROM noted to R ankle due to swelling.  MUSCULOSKELETAL: Feet are in alignment with bilateral tibias. Weight bearing is midline on L foot and on dorsal side on R foot, due to pain. Rounded malleolar prominences, prominent heels, and prominent metatarsophalangeal joints. No bunions, calluses, or corns noted to bilateral feet. Toes are straight, flat, and in line with each other. No pain with palpation of metatarsophalangeal joints noted. Tenderness and swelling noted to R anterior inferior tibiofibular ligament with dorsiflexion, external rotation, and weight bearing. OTTAWA ANKLE RULES negative, no bone tenderness along the distal 6 cm of the posterior edge of the fibula or tip of the lateral malleolus, or medial malleolus. Patient can bear weight for 6 steps (Foster, 2018). Diagnostic results: Xray of bilateral ankles and lower legs; to rule out fracture. MRI to diagnose ankle syndesmosis, ligament injury, and bone injuries. CT to diagnose soft tissue injuries, or bone injury. 

A. Differential Diagnoses: Soft-tissue injury-sprained ankle: The most common soft tissue injury is to muscles, tendons, and ligaments. Most of these injuries occur during the patient participating in sports, or exercise. At times day-to-day activities can cause soft tissue injuries. Soft tissue injuries have a prolonged healing time due to continued use (Boston Medical Center, n.d.). With patient’s symptoms this is most likely the diagnosis of choice. Follow up would be needed if patient’s symptoms do not improve. 

Fracture: Can be in varying degrees, presented patient can bear weight on foot, she does not state pain is severe, no increased pain with palpation, and only slight bruising noted to ankle. Diagnostic Xray can be completed to rule out (professional, n.d.). 

Ankle impingement: defined as pain with impingement to either the anterior or posterior aspect of the ankle. Usually, pain is localized at the tibiotalar joint. This injury usually occurs with compression of structures in ankle. Pain occurs with soft tissue inflammation. Patient does have limited movement to R foot due to swelling to ankle. No increase in pain with movement (Physiopedia, n.d.).   

Rheumatoid arthritis (RA): This could be a possible diagnosis after further testing if the diagnostic testing completed is negative. RA is an autoimmune and inflammatory disease and occurs in the hands, wrists, knees, and at times ankles. The lining of the joint becomes inflamed causing further damage (CDC, 2020).

Tendonitis: This occurs with inflammation of a tendon, causing swelling, and pain. Can occur with overuse, injury, RA, or infection. This diagnosis could be ruled out as the patient does not increased pain with movement. 

References Ankle injuries. Penn State Student Affairs. (n.d.).  https://studentaffairs.psu.edu/health-wellness/healthcare-and-medical-services/health-information-resources/ankle-injuries Links to an external site. .

Ankle impingement. Physiopedia. (n.d.).  https://www.physio-pedia.com/Ankle_Impingement.  Links to an external site.

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Seidel's guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby.

Centers for Disease Control and Prevention. (2020, July 27). Rheumatoid arthritis (RA). Centers for Disease Control and Prevention.  https://www.cdc.gov/arthritis/basics/rheumatoid-arthritis.html#:~:text=Rheumatoid%20arthritis%2C%20or%20RA%2C%20is,affected%20parts%20of%20the%20body.  Links to an external site.

Foster, T. (2018, November 3). Ottawa Ankle Rules: Radiology Reference Article. Radiopaedia Blog RSS.  https://radiopaedia.org/articles/ottawa-ankle-rules-1?lang=us Links to an external site. .

professional, C. C. medical. (n.d.). Broken ankle (ankle fractures): Symptoms, causes & treatment. Cleveland Clinic.  https://my.clevelandclinic.org/health/diseases/21644-broken-ankle Links to an external site. .

Sprains, strains & soft-tissue injuries. Boston Medical Center. (n.d.). https://www.bmc.org/sprains-strains-soft-tissue-injuries.