Wk8

A 46-year-old female reports pain in both of her ankles, but she is more concerned about her right ankle. She was playing soccer over the weekend and heard a "pop." She is able to bear weight, but it is uncomfortable. In determining the cause of the ankle pain, based on your knowledge of anatomy, what foot structures are likely involved? What other symptoms need to be explored? What are your differential diagnoses for ankle pain? What physical examination will you perform? What special maneuvers will you perform? Should you apply the Ottawa ankle rules to determine if you need additional testing?

With regard to the case study you were assigned:

Review this week's Learning Resources, and consider the insights they provide about the case study.

Consider what history would be necessary to collect from the patient in the case study you were assigned.

Consider what physical exams and diagnostic tests would be appropriate to gather more information about the patient's condition. How would the results be used to make a diagnosis?

Identify at least five possible conditions that may be considered in a differential diagnosis for the patient

used the template below

Episodic/Focused SOAP Note Template

Patient Information:

Initials, Age, Sex, Race

S.

CC (chief complaint) a BRIEF statement identifying why the patient is here - in the patient’s

own words - for instance "headache", NOT "bad headache for 3 days”.

HPI: This is the symptom analysis section of your note. Thorough documentation in this section

is essential for patient care, coding, and billing analysis. Paint a picture of what is wrong with the

patient. Use LOCATES Mnemonic to complete your HPI. You need to start EVERY HPI with

age, race, and gender (e.g., 34-year-old AA male). You must include the seven attributes of each

principal symptom in paragraph form not a list. If the CC was “headache”, the LOCATES for the

HPI might look like the following example:

Location: head

Onset: 3 days ago

Character: pounding, pressure around the eyes and temples

Associated signs and symptoms: nausea, vomiting, photophobia, phonophobia

Timing: after being on the computer all day at work

Exacerbating/ relieving factors: light bothers eyes, Aleve makes it tolerable but not

completely better

Severity: 7/10 pain scale

Current Medications: include dosage, frequency, length of time used and reason for use; also

include OTC or homeopathic products.

Allergies: include medication, food, and environmental allergies separately (a description of

what the allergy is ie angioedema, anaphylaxis, etc. This will help determine a true reaction vs

intolerance).

PMHx: include immunization status (note date of last tetanus for all adults), past major

illnesses and surgeries. Depending on the CC, more info is sometimes needed

Soc Hx: include occupation and major hobbies, family status, tobacco & alcohol use (previous and current use), any other pertinent data. Always add some health promo question here - such as

whether they use seat belts all the time or whether they have working smoke detectors in the

house, living environment, text/cell phone use while driving, and support system.

Fam Hx: illnesses with possible genetic predisposition, contagious or chronic illnesses. Reason

for death of any deceased first degree relatives should be included. Include parents, grandparents,

siblings, and children. Include grandchildren if pertinent.

ROS: cover all body systems that may help you include or rule out a differential diagnosis You

should list each system as follows: General: Head: EENT: etc. You should list these in bullet

format and document the systems in order from head to toe.

Example of Complete ROS:

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

HEENT: Eyes: No visual loss, blurred vision, double vision or yellow sclerae. Ears, Nose,

Throat: No hearing loss, sneezing, congestion, runny nose or sore throat.

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.

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

blood.

GENITOURINARY: Burning on urination. Pregnancy. Last menstrual period, MM/DD/YYYY.

NEUROLOGICAL: No headache, dizziness, syncope, paralysis, ataxia, numbness or tingling in

the extremities. No change in bowel or bladder control.

MUSCULOSKELETAL: No muscle, back pain, joint pain or stiffness.

HEMATOLOGIC: No anemia, bleeding or bruising.

LYMPHATICS: No enlarged nodes. No history of splenectomy.

PSYCHIATRIC: No history of depression or anxiety.

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

polydipsia.

ALLERGIES: No history of asthma, hives, eczema or rhinitis.

O.

Physical exam: From head-to-toe, include what you see, hear, and feel when doing your

physical exam. You only need to examine the systems that are pertinent to the CC, HPI, and

History. Do not use “WNL” or “normal.” You must describe what you see. Always

document in head to toe format i.e. General: Head: EENT: etc.

Diagnostic results: Include any labs, x-rays, or other diagnostics that are needed to develop the

differential diagnoses (support with evidenced and guidelines)

A.

Differential Diagnoses (list a minimum of 3 differential diagnoses).Your primary or

presumptive diagnosis should be at the top of the list. For each diagnosis, provide supportive

documentation with evidence based guidelines.

P.

This section is not required for the assignments in this course (NURS 6512) but will be required

for future courses.

References

You are required to include at least three evidence based peer-reviewed journal articles or

evidenced based guidelines which relates to this case to support your diagnostics and

differentials diagnoses. Be sure to use correct APA 6th edition formatting.