Assessment of the Musculoskeletal System-Focused SOAP Note Assignment

Assessment of the Musculoskeletal System-Focused SOAP Note Assignment

Assessment of the Musculoskeletal System-Focused SOAP Note Assignment

Patient Information:

Initials: MO

Age: 46 years

Sex: Female

Race: African American

S.

CC (chief complaint) Bilateral ankle pain that is worse on the right ankle (Case #2 Ankle pain)

HPI: MO is a 46-year-old African American female patient who has visited the outpatient clinic for evaluation. She presents with complaints of bilateral ankle pain. She, however, has more concerns regarding the pain in the right ankle. The onset of the pain was preceded by a pop sound while the patient was playing soccer over the weekend. The patient reports that she can bear weight but then experiences discomfort.

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Location: Bilateral ankle pain but worse on the right

Onset: A few days ago

Character: Constant pain that was preceded by a pop sound and is more on the right ankle

Associated signs and symptoms: discomfort that follows weight-bearing, and joint swelling

Timing: During the weekend while playing soccer

Exacerbating/ relieving factors: The pain is exacerbated by any activity that results in weight-bearing such as movement and causes discomfort. It is partially relieved by rest and over-the-counter painkillers.

Severity: 6/10 pain scale

Current Medications: The patient has been on over-the-counter paracetamol 1g three times per day for the last three days. This is intended to relieve the pain. The patient also applies cold compresses to the ankles in the morning and evening to reduce the pain and swelling. She also bandaged the ankles for fixation to reduce movements that exacerbate her pain and discomfort.

Allergies: The patient reports no allergies to any prescription medication, food, or environmental components.

PMHx: The patient received the Moderna COVID-19 vaccine in 2020. The last tetanus vaccine was eight years ago during antenatal care of her last pregnancy.

Soc Hx: The patient is a soccer player.

Fam Hx: There are no reported genetic or chronic conditions in the patient’s family.

 

ROS:

GENERAL:  The patient reports no unintentional weight loss and no fever.

HEENT: The patient denies any visual disturbance, hearing loss, sore throat, or nasal congestion.

SKIN: There is no reported itchiness or skin rash.

CARDIOVASCULAR:  The patient denies awareness of heartbeat, left-sided chest pains, or lower limb edema.

RESPIRATORY:  There is no cough, no dyspnea, and no chest pain.

GASTROINTESTINAL:  She denies any vomiting, change in bowel habits, blood in stool, and abdominal pain.

GENITOURINARY:  She denies any dysuria, hematuria, frequency, or urinary incontinence.

NEUROLOGICAL:  There are no reported headaches, dizziness, convulsions, or neurological deficits.

MUSCULOSKELETAL:  She reports bilateral ankle pain, and swelling.

HEMATOLOGIC:  She reports no anemia, no bleeding tendency, and no easy bruising.

LYMPHATICS:  Patient denies lymph enlargement or splenomegaly.

PSYCHIATRIC:  There is no history of any psychiatric condition.

ENDOCRINOLOGIC:  There are no reports of heat or cold intolerance, excessive sweating, polydipsia, polyphagia, or polyuria.

ALLERGIES:  Denies any allergic reactions or atopic conditions.

O.

Physical exam:

GENERAL: The patient is in a fair general condition, and not in distress.

MUSCULOSKELETAL: On inspection, there is swelling and redness of both ankles that is more on the right lower limb. There are no scars, no skin disruption, and no discoloration of surrounding skin. There is tenderness on palpation. All the pulses are present, regular, and of good volume. The sensation is intact. There are mild restrictions on the range of movement of the ankle joint which is more on the right. This may be attributed to ankle pain. The muscle tone and bulk are normal. There is a mild weakness of the ankle joint.

Diagnostic results:

Ankle X-Ray: This will be performed based on Ottawa ankle rules. Indications for X-ray include pain on the posterior edge of distal 6 cm or the tip of the either malleoli, loss of weight-bearing ability immediately after injury, the presence of bone tenderness at the base of the fifth metatarsal bone or over the navicular bone, and inability to attain a minimum of four steps in the emergency department (Yavas et al., 2021). The objective of this rule is to avoid unnecessary exposure to radiation by predicting the need for X-rays for acute ankle injuries

Orthopedic special tests: These tests aid in the diagnosis and extent of ankle sprains following injuries. The anterior drawer test, posterior-anterior drawer test, prone anterior drawer test, anterolateral drawer test, inversion stress test, and posterior drawer test assess for strains in the lateral collateral ligaments of the ankle (Larkins et al., 2020). Sprains of the medial collateral ligaments are evaluated by the eversion stress test, and Kleiger’s test (Larkins et al., 2020). These tests, together with a comprehensive history and further evaluation is useful in formulating an accurate diagnosis.

A.

Differential Diagnoses

Achilles tendon rupture: This is the most likely diagnosis. Achilles tendon rupture presents with a hallmark of a popping sound and other features such as ankle pain, swelling, reduced ability to bear weight, and limitations in the range of motion (Shamrock et al., 2022). The patient presented with these typical features thus supporting this diagnosis.

Acute ankle sprain: This is another likely diagnosis. Acute ankle sprains are a common sports-related injury that presents with ankle pain, swelling, limitations in the range of motion, and reduced weight-bearing ability (Halabchi et al., 2020). The popping sound heard before the onset of pain reduces the possibility of this diagnosis.

Ankle fracture: This is another likely diagnosis. Ankle fractures present with an inability to bear weight, ankle pain, swelling, bruising, gross deformity, and associated soft tissue injury (Lampridis et al., 2018). High energy is mostly the cause of injury which is not the case with this patient. It is also unlikely since the patient can bear weight with only discomfort being experienced.

Ankle arthritis: This is a possible diagnosis. Arthritis presents with joint pain, warmth, swelling, stiffness, and reduced range of motion (Adukia et al., 2020). The pop sound and occurrence of symptoms during soccer cannot explain this diagnosis.

Calcaneus fractures: Fractures of the calcaneus present with pain, swelling, ecchymosis, and inability to bear weight (Davis et al., 2022). The fact that the patient can bear weight rules out this diagnosis.

This section is not required for the assignments in this course but will be required for future courses.

References

Adukia, V., Mangwani, J., Issac, R., Hussain, S., & Parker, L. (2020). Current concepts in the management of ankle arthritis. Journal Of Clinical Orthopaedics And Trauma, 11(3), 388-398. https://doi.org/10.1016/j.jcot.2020.03.020

Davis, D., Seaman, T. J., & Newton, E. J. (2022). Calcaneus Fractures. In StatPearls. StatPearls Publishing.

Halabchi, F., & Hassabi, M. (2020). Acute ankle sprain in athletes: Clinical aspects and algorithmic approach. World Journal Of Orthopedics, 11(12), 534-558. https://doi.org/10.5312/wjo.v11.i12.534

Lampridis, V., Gougoulias, N., & Sakellariou, A. (2018). Stability in ankle fractures. EFORT Open Reviews, 3(5), 294-303. https://doi.org/10.1302/2058-5241.3.170057

Larkins, L., Baker, R., & Baker, J. (2020). Physical Examination of the Ankle: A Review of the Original Orthopedic Special Test Description and Scientific Validity of Common Tests for Ankle Examination. Archives Of Rehabilitation Research And Clinical Translation, 2(3), 100072. https://doi.org/10.1016/j.arrct.2020.100072

Shamrock, A. G., & Varacallo, M. (2022). Achilles Tendon Rupture. In StatPearls. StatPearls Publishing.

Tarantino, D., Palermi, S., Sirico, F., & Corrado, B. (2020). Achilles Tendon Rupture: Mechanisms of Injury, Principles of Rehabilitation and Return to Play. Journal Of Functional Morphology And Kinesiology, 5(4), 95. https://doi.org/10.3390/jfmk5040095

Yavas, S., Arslan, E. D., Ozkan, S., Yilmaz Aydin, Y., & Aydin, M. (2021). Accuracy of Ottawa ankle rules for midfoot and ankle injuries. Acta bio-medica : Atenei Parmensis, 92(4), e2021241. https://doi.org/10.23750/abm.v92i4.9962.

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Write an episodic/focused note about the patient in the case study to which you were assigned using the episodic/focused note template. Provide evidence from the literature to support diagnostic tests that would be appropriate for each case. List five different possible conditions for the patient’s differential diagnosis and justify why you selected each.

Case #2 Ankle pain
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?