response to discussion

RESPOND TO #1

Patient Information:

C.E., 46, F, Caucasian

 

S.

CC: "Pain on both ankles."

 

HPI: C.E. is a 46-year-old female who sought treatment due to pain in both of her ankles. Today, she reported that she is more worried about her right ankle. C.E. relayed that she was playing soccer two days ago when she heard a pop on her right ankle. She relayed that she noticed some swelling, bruising, and stiffness with decreased mobility on her right ankle. C.E. also added that she could walk on her right ankle but with discomfort. She reported that she did a cold compress and took Tylenol, which helped with the pain. C.E. also verbalized that she needs to rest and elevate her right leg for some relief when walking. Presently, she rated her pain as 5/10.

 

Current Medications: She takes Centrum Silver once daily.

 

Allergies: Pistachio nuts – Itchiness and rashes

 

PMHx: She has no history of medical illnesses or past surgeries. The patient's vaccination record is updated. The latest tetanus shot was three years ago. 

 

Soc Hx: C.E. has been married for 16 years and has two children. She lives with her husband and two children. C.E. works as a Physical Education teacher and handles the soccer team. She denied smoking, drinking alcohol, or use of illicit drugs. 

 

Fam Hx: Father has hyperlipidemia. Her mother, children, and grandparents on both sides have no medical illnesses.

 

ROS:

· GENERAL: No fever or weakness.

· SKIN: No lesion or rashes.

· CARDIOVASCULAR: No chest discomfort or edema.

· RESPIRATORY: No cough or shortness of breath.

· NEUROLOGICAL: No radiation, paresthesia, tingling, or burning 

· MUSCULOSKELETAL: (+) bilateral ankle pain

 

O.

Physical exam: 

· Vital Signs: B.P.: 111/74 mmHg, H.R.: 77, R.R.: 19 cpm, T: 97.6 F, Ht: 5’8”, Wt. 122 lbs.,

· BMI: 23.8 (normal)

· GENERAL: The patient is alert and oriented. She is not in acute distress. She has a noticeable limp while walking.

· SKIN: (+) bruising, (+) inflammation on right ankle

· CARDIOVASCULAR: Adynamic precordium. Normal rate and regular rhythm. No murmur, gallops, or rubs. 

· RESPIRATORY: Clear vesicular breath sounds. Normal resonant percussion. 

· MUSCULOSKELETAL: Right ankle: Can bear weight, (+) bruising, (+) inflammation, (+) tenderness, (+) 8 degrees limited range of motion, (+) anterior drawer test, and (-) talar tilt test. Left ankle: Can bear weight, (-) inflammation, (-) limited range of motion,

(-) bruising, (-) tenderness, (-) anterior drawer test, and (-) talar tilt test.

· LYMPHADENOPATHY: No cervical, axillary, and inguinal lymphadenopathy.  

 

Diagnostic results:

 

· Comprehensive history taking is diagnostic. The mechanism of the injury, history of past ankle injuries, and weight-bearing ability after the injury should be obtained to help determine the diagnosis (Dains et al., 2019; Melanson & Shuman, 2021).

 

· Physical examination is also diagnostic. Therefore, inspection, palpation, and testing of the ankle's function should be done. (Dains et al., 2019). Moreover, the Ottawa Ankle Rules can be used initially to evaluate ankle fractures and determine if the patient requires x-rays or not (Melanson & Shuman, 2021; Husted, 2019).

 

· If radiography is to be done, a series of x-ray should comprise anteroposterior, lateral, and mortise views (Dains et al., 2019; Melanson & Shuman, 2021).

 

A.

Differential Diagnoses:

1. Lateral ankle sprain (LAS) grade II – C.E. came in due to bilateral ankle pain but was more concerned about her right ankle. The symptom started two days ago after playing soccer. Upon physical examination, the findings for the right ankle indicated bruising, inflammation, tenderness, limited range of motion, and anterior drawer test, but negative talar tilt test. This clinical presentation means that LAS grade II is an appropriate diagnosis for this patient. LAS is a musculoskeletal injury that is frequently incurred by people who engage in sports. In grade II LAS, there is some loss of function, positive anterior drawer test, negative talar tilt test, bruising, point tenderness, decreased range of motion of more than 5 degrees but less than 10 degrees, and swelling more than 0.5 cm but less than 2.0 cm (Vuurberg et al., 2018; Wells et al., 2019). 

 

2. High ankle sprain (syndesmotic injury) – Syndesmotic injury happens when the high ankle ligaments above the ankle are torn or damaged. The usual cause of this disorder includes accidental twisting or rotation of the ankle. Symptoms include the inability to bear weight on the affected ankle and increased pain with activities like climbing stairs (FootCareMD, 2020). This patient came in with pain in both ankles, specifically the right ankle. However, the patient can bear weight despite increased pain when walking. Also, the patient did not endorse accidental twisting or rotation of her right ankle. 

 

3. Tarsal Tunnel Syndrome (TTS) – This condition is due to dysfunction of the tibial nerve or neuralgia of the posterior tibial nerve. TTS is the outcome of squeezing one of the two branches of the posterior tibial nerves. Approximately 43% of patients who have TTS sustained it from trauma like an ankle sprain. The main symptoms include shooting pain in the foot, numbness, radiation, paresthesia, pain upon dorsiflexion and eversion, tingling or burning sensation (Kiel & Kaiser, 2021). Since the patient complained of pain due to playing soccer, TTS was considered. However, her pain is not associated with numbness, radiation, paresthesia, tingling, or burning. 

 

4. Achilles Tendon Rupture (ATR) – This is the result of a partial or complete tear of an overstretched Achilles tendon. Usual activities like powerful leaping or pivoting, abrupt spurts of running can cause ATR. Symptoms may include sudden pain, popping or snapping feeling, swelling between the calf and the heel, and difficulty walking (American College of Foot and Ankle Surgeons, 2021). C.E. complained of pain and a popping sound while playing soccer. She also has swelling and difficulty walking, which can be linked to ATR. Yet, her pain is not sudden, and the swelling is not between the calf and the heel.

 

5. Ankle impingement syndromes (AIS) – This complex condition could be an outcome of trauma in athletes or due to chronic degenerative changes. It is characterized by pain on the ankle joint with specific movements and a limited range of motion (Berman et al., 2017). Since this patient contracted her ankle pain after playing soccer and has a limitation on the range of motion on her right leg, AIS was suspected. However, C.E. has pain even at rest.