Christina Alvarez
1 day ago
Alvarez: Ankle Injury
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Episodic/Focused SOAP Note: Ankle Injury
Patient Information: F.P, 46 y/o, Hispanic, Woman
S.
CC: Right ankle pain. “I was playing soccer over the weekend and heard a pop.”
HPI: Patient, F.P., is a 46-year-old Hispanic woman who presents in the clinic today complaining of bilateral ankle pain, with right ankle of primary concern. She states she was playing soccer 2 days ago and heard a “pop”. She further states she heard the “pop” after running approximately 50 yards. She denies recent trauma or fall. She describes the pain as sharp when bearing weight, and dull/throbbing when she is at rest. She is able to bear weight but is uncomfortable. The pain is constant but worse when she bears weight. She rates the pain at its worst as a 7/10 and at its best 2/10. Pain is reproducible with palpation. The pain does not radiate. Patient states she did not apply ice to the injured ankle, and has only taken 200 mg of Ibuprofen, which she took 2 days ago and provided no relief. Patient states she doesn’t like to take medicine for pain one only took one tablet. She reports no associated signs and symptoms.
Current Medications: no prescription medications; centrum complete multi-vitamin daily, ibuprofen, 200 mg; denies homeopathic products.
Allergies: No known medication allergies. Denies environmental, food, and latex allergies.
PMH: Reports history of insomnia, never treated. Denies having major illnesses, surgical procedures and hospitalizations. Reports being up-to-date on vaccinations. Last tetanus shot was 09/2019 – as preventative measure. Flu vaccination given 10/2019. SH: F.P. is a single woman with no children. She lives in a home she owns and is independent. She works as an online life coach and operates from her home. She lives alone with four dogs and a lizard. She denies drinking alcohol, smoking/vaping, using nicotine products, and recreational drugs. She endorses drinking 1-2 cups of coffee daily. She drives routinely, does not text-and-drive, and wears seatbelts. Her home is equipped with NEST home security and fire/carbon dioxide detectors. She has been celibate for the last three years and has practiced safe-sex. She is not currently on birth control, and her last menstrual cycle started 2-days ago. She denies having any sexually transmitted diseases. She participates in a local soccer league, and has for the last 10 years. She plays soccer every weekend and participates in hot yoga 3 times a week. She reports that her living environment is safe and her dogs are well-behaved and provide “all the emotional support I need.”
FH: Mother, died at 69 of lung cancer; father, 75, living, high blood pressure, high cholesterol, osteoarthritis; Paternal grandmother, died at 70, complications from osteoporosis/diabetes; Paternal grandfather, died at 78, heart attack; Maternal grandmother, died at 98, ruptured aortic aneurysm; Maternal grandfather, died at 78, complications from Alzheimer’s. Patient has no siblings or children.
ROS:
· GENERAL: No weight loss, fever, chills, weakness or fatigue.
· CARDIOVASCULAR: No chest pain, chest pressure, chest discomfort, 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: No muscle, back pain, or stiffness. Pain and swelling on lateral aspect of right ankle
· SKIN: No rash or itching
O.
· VS: BP 110/70, HR 65, Resp 16, Temp 98.4, O2 100%, Ht: 5’5”, Wt: 170 lbs.
· GENERAL: Alert and oriented x 3, appropriate, calm, cooperative
· CARDIOVASCULAR: s1s2, no murmur, no edema, pulses equal +2
· RESPIRATORY: Lungs clear to auscultation bilaterally, no rhonchi or wheezes, expansion equal and symmetric
· NEUROLOGICAL: Equal strength (+5), equal sensation, no numbness, no decrease in sensation in upper and lower extremities. No ataxia.
· MUSCULOSKELETAL: smooth and rounded malleolar prominences, prominent heels, and prominent metatarsophalangeal joints. No calluses or corns. Feet are aligned with tibias. Weight bearing in on the midline of feet. Longitudinal arch. Toes are straight forward, flat, and in alignment with each other. No pain upon palpation of bilat metatarsophalangeal joints. No heat or redness on bilat ankles/feet. (+) Swelling and tenderness on anterior-inferior tibiofibular ligament with dorsiflexion-external rotation and weight-bearing. Bilat dorsiflexion of 20 degrees; inversion of 30 degrees, eversion of 20 degrees, abduction of 10 degrees and adduction of 20 degrees, flexion and extension of all toes bilaterally. No signs of instability in bilat hips or knees. (-) OTTAWA ANKLE RULES: No bone tenderness along the distal 6 cm of the posterior edge of the fibula or tip of the lateral malleolus, medial malleolus. Patient is able to bear weight for 4 steps.
· SKIN: Skin intact, no rash
Diagnostic results:
· X-rays of the ankle and lower leg: Ottawa Ankle Rules should be assessed before ordering radiographs (O’Neill, 2019). In the case of patient F.P. the Ottawa Ankle Rules do not apply. X-rays are used to rule-out fracture. Reliability and validity of x-ray’s being used to diagnose ankle syndesmosis have been found to be questionable (Chun et al., 2019). Plain radiographs can be used to confirm a diagnosis of ankle impingement (Talusan, Toy, Perez, Milewski, & Reach, J., 2014). X-rays are also used to diagnose osteochondritis dissecans (OCD) (American Academy of Orthopaedic Surgeons (AAOS), n.d.)
· Magnetic Resonance Imaging (MRI): MRI has the highest specificity and sensitivity in diagnosing ankle syndesmosis (Chun et al., 2019). MRI can be used to diagnose ligament injury, and subtle bone injuries (Dearde, Reeve, & Sharpe, 2018), and evaluate the extent of OCD (AAOS, n.d.)
