Description
Case 2: Ankle PainA 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?Post an episodic/focused note about the patient in the case study to which you were assigned using the episodic/focused note template provided in the Week 5 resources. 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.
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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
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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.
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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.
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