Case Study

Discussion post reply to the following soap noted case scenario.

Respond by analyzing Analyze the possible conditions from your colleagues’ differential diagnoses. Determine which of the conditions you would reject and why. Identify the most likely condition, and justify your reasoning.

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2 to 3 scholarly references with in the last 5 years

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Case scenario # 1

Sibongile M

Week 8, Mpofu Sibongile C

1/18/2023

Review of Case Study # 2 Ankle Pain SOAP Note.

Patient Information: Name: MF

Initials, MF Age: 46-year-old Sex: Female, Caucasian.

CC: “My Ankles Hurts, worse on the right ankle”.

HPI: MF is a 46-year-old Caucasian female who presents to the clinic this morning with bilateral ankle pain, worse on the right foot it hurts and very uncomfortable. She reports pain started two days ago after playing soccer over the weekend, she says she heard a “pop”. It is a throbbing pain, that gets worse when she bears weight on it when standing or walking but gets better when she applies ice and rest with feet elevated. She states the pain as constant all day, associated with swelling. She rates her pain as 3/10 left ankle but right ankle is 7/10.

Current Medication:

1. Ibuprofen 400 mg x 2 PO 8 hrly prn for pain. Has been taking it for 2 days ago.

2. Tylenol 650 mg PO 6 hourly for pain. Since last night.

3. Ice packs, twice daily for pain.

4. Fish oil 1200 mg PO, HS for pain

Allergies: No Known allergies to drugs nor food allergies .

PMH: MF is up to date with her immunization, has covid-19 vaccine in June 2022. (Pfizer). Second dose on September 15th, 2022. Tetanus vaccine a year ago but cannot recall the date. Is getting flu vaccine end of the month. Made up history. Sprained her ankle 2 years ago,2020. No previous surgeries.

Soc History: She is a high school sports teacher. Married for 6 years, no children. She enjoys outdoor activities walking, camping, playing soccer and shopping. She lives with her husband in a 3-bedroom house, secure community. She does not smoke but drinks alcohol, a glass of wine during dinner and beer during weekends only if no sports. Denies drugs use. She drives herself to work, wears seat belts, she only answers the phone using her Bluetooth. She eats healthy diet and exercises 3 times a week on her treadmill and plays sports (soccer) every Friday afternoon and Saturday from 4 pm to 6pm. She gets support from her husband and is a member of teachers support group.

Fam Hx:

1. Mother: 72 years. Type 2 diabetes, on diet control, diagnosed 3 years ago alive.

2. Father: Father 78 years with gout, is alive.

3. Sister: 40 years with arthritis alive

4. Maternal grandmother: died at 80 years from hypertension.

5. Maternal grandfather: died at 68 years from COPD.

6. Paternal grandfather: Died from heart attack at 70 years.

7. Paternal grandmother: died at 80 years, unknown cause, but had arthritis.

ROS:

General: MF appears healthy, she weighs 156 lbs. denies weight loss or weight gain. No chills or fever. She is a little fatigue since injury. Does not sleep well due to pain.

HEENT:

Head: Normocephalic, no trauma.

Eyes: Clear, no eye discharge, sclera clear no yellow discoloration(jaundice). Denies change in vision, blurry, or double vision. Does not wear glasses or contact lenses.

Ears: Bilateral equal, no tinnitus, no hearing loss, or ear discharge.

Nose: No epistaxis, no running nose, pressure, or postnasal drip, nor congestion.

Throat: No sore throat, no tonsilitis, no hoarseness, no difficulties in swallowing. No dental ulcers, no bleeding gums, dental curies

SKIN: Edema 1+ right ankle, warm, dry, and intact. No itching or rash.

Cardiovascular: No palpitations, chest pains, but has edema of the lower limbs (Right ankle) no SOB. No history of cyanosis or heart murmur.

Respiration: denies coughing, no dyspnea, or tightness, asthma No cyanosis. shortness of breath, cough, or sputum.

Gastrointestinal: No nausea and vomiting, no abdominal pains, no constipation, or bloody stool

Genitourinary: denies dysuria, hematuria, or frequency. Last menstrual periods 3 months ago.10/22/2022. Started menarche at 14 years. Has irregular periods. Had 2 miscarriages at 20 years and 22 years of age.

Neurological: Denies headache, dizziness, syncope, no headache paralysis, ataxia, numbness/ tingling in the extremities. No frequency or loss of bowel control.

Musculoskeletal: Bilateral limited range of movement due to pain. No fracture. Right ankle is swollen. Denies back pain or history of arthritis No stiffness but has history of sprain couple of years ago.

Hematology: No anemia, bleeding, or bruising.

Lymphatics: No enlarged nodes. No history of splenectomy.

Psychiatric: No history of depression or anxiety, she sleeps well except during pain. No suicidal ideas

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

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

Physical exam:

Vital signs – BP 122/68 Pulse 78 b/min, temp 98.8 orally, Resp 17 weight 156 lbs. height 5’ 5”. (made up information)

General: MF appears comfortable. Answers questions clear and maintains eye contact. She is well groomed, no signs of distress has mild discomfort on touch during examination (facial grimace).

Musculoskeletal: Muscles well developed as per age. No weakness of muscles. There is tenderness on rotation of both ankles more on the right ankle. Stiffness during dorsiflexion, bilateral. 1+ edema on the right ankle. Other limbs and joints are unremarkable. Positive pedal pulses, reflexes 2+. Nerves intact (peroneal nerve) (McCance & Huether, 2019).Can not bear weight on the right foot.

Respiration: Lungs bilateral clear, no wheeziness, no SOB. (dyspnea)

Cardiovascular/ peripheral: No heart palpitations, has mild bruise on the right ankle. No discomfort on percussion. No heart murmur on auscultation. No jugular vein distention. Pulses are pos, popliteal, pedal anterior and posterior.

Skin: Warn on touch, pink but bruised left ankle. No rash or any blisters

Neuro: Clear intact and pos sensation. Extremities holds strong muscle strength, no muscle atrophy. Right ankle tender and edematous.

Diagnostic results: Radiography: X-ray of both ankles, this will reveal any fractures and any bone abnormalities. (Ball, et al 2019). Ottawa Ankle Rules. Formulated in Canada (1992) This a series of ankle radiograph films that is used when there is any pain in malleolar zone. Bone tenderness and inability to bear weight. (Young, 2019). Ottawa ankle rule are 97.5% reliable and reduces radiography by 35% (Young,2019).

MRI: MRI will reveal soft tissue injury, and ligaments injuries. (Jung, et al 2017)

Kleiger test: This is external rotation test to assess the integrity of the muscles and deltoid ligament injury. (Molis,2018)

Talar tilt test. (Hunter, et al 2019)

Assessment .

Differential Diagnoses

1. Foot and Ankle sprain. This diagnosis is selected first because it occurs after excessive stretching or forceful contraction beyond foot capacity, especial during sports. It can be associated with previous injury, and it has swelling and bruising as a sign. (Young,2019)

2. Calcaneofibular ligament sprain. This ligament pain is very common and is acute. It presents with bruising, pain at the lateral side of the ankle and edema. According to Hunt et al 2019, talar tilt test can diagnose it (Hunter, et al 2019)

3. Fracture of the ankle /foot. A fracture can be partial or complete break of the bone. Leading to pain, deformity, edema, and loss of function. X-ray and MRI will be used to diagnose the fracture. (McCance & Huether, 2019).

4. Achilles Tendinitis. This is a soft tissue injury, accompanied be swelling, and pain. It is caused by activity strain example running and jumping mostly during sports, however there is no stiffness. (Dains, Baumann, & Scheibel, 2019)

5. Ligament tear: LT presents with the inability to bear weight on the affected limb, there is pain and swelling following a popping sound at the injury time. (Molis,2019)

Case scenario # 2

Robert A

Patient Information:

JW, 42-year-old white male

CC “my back has been hurting for a month”

HPI: JW, 42-year-old white male who came to the emergency department this morning with intermittent backpain, radiating to the rear of his left leg. He states pain started at work but was unaware of specific incident or injury, noting that pain not increased in morning time. JW reports pain can make walking difficult, limiting activity.

Location: lower back

Onset: 1 month prior

Character: aching, spasms

Associated signs and symptoms: tenderness localized to left of spine, limited spinal motion and hip/gluteal pain

Timing: pain increases with activity and bending

Exacerbating/ relieving factors: extended, vigorous activity makes pain intolerable; Aleve makes it tolerable but not completely better. Heating pad and rest reports relief

Severity: 7/10 pain scale

Current Medications: Aleve 400 mg TID PRN, Omeprazole 20 mg OTC PRN

Allergies: no known drug allergies, no known food allergies or intolerances, no known environmental allergies, denies allergy to latex

PMHx:

Immunizations: current influenza, 3 doses of Moderna covid vaccine, all regular childhood vaccinations, tetanus 2017

Surgical history: Appendectomy 2020, vasectomy 2021

Past Medical history: GERD Soc Hx: JW is employed as a nurse who enjoys gardening and weight lifting in his free time. He is currently married and lives in a house that has running water, internet and cell service. He reports feeling safe in his current home environment and has an active support system

Tobacco use: denies

Alcohol use: socially on weekends

Illicit drugs: denies

Fam Hx:

Mother: living 67 HTN, DM2

Father: living 67 HLD, HTN, MI

Paternal Grandmother: died 77 covid PNA 2022

Paternal grandfather: died 72 MI, HTN, HLD

Maternal grandmother: living 80 Alzheimer’s, HLD

Maternal grandfather: died 75 stroke, HLD and HTN

Brother: living 39, obesity, HTN

Son: living 21

ROS:

GENERAL: No weight loss, fever, chills or fatigue. Denies night sweats

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.

NEUROLOGICAL: No headache, dizziness, syncope, paralysis. Reports ataxia, numbness and tingling in the left lower extremity with exertion. No change in bowel or bladder control.

MUSCULOSKELETAL: reports back pain, worse with exertion and easily fatigued. Reports of stiffness in back

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.

Physical exam:

Vital signs: 125/66 MAP 86, 81 BPM, 16 Resp, 37 T, 168 lbs., 5’9”, BMI 24.8, Pain 7/10

General: well developed middle aged male, well groomed and dressed appropriately for the season. He is conversational and cooperative, oriented and in no apparent distress.

Head: atraumatic and normocephalic

Neuro: alert and oriented, movements purposeful and fluid. No weakness noted in left leg on extension/flexion, paresthesia noted in left lower extremity radiating from lower back.

Respiratory: normal work of breath, clear breath sounds, atraumatic visual inspection

Cardiovascular: S1S2 intact, no rub or murmurs appreciated. Popliteal pulses +2, dorsal pedal +2, post tib +2. Feet are warm and pink with cap refill >3 seconds

GI: no masses or tenderness on palpation, bowel sounds present in all quadrants

Musculoskeletal: cervical spine and cervical rom intact, thoracic spine normal to inspection, noted tenderness or left lower lumbar spine. Pain radiating to left hip/buttock, pain free on right. Straight leg raises test negative, sit to stand negative, lower extremity paresthesia reported on left radiating from back, reflexes equal

Diagnostic results:

Thoracic/Lumbar CT- will show deformities, abscesses, tumor and kidney stones (Kim, L,,et al.,2019) the passing straight leg raise test relies burden of MRI (Pesonen, J. et al 2021)

CBC- noting white blood cell count, if elevated add blood cultures. Our patient has a high-risk job for MRSA infection, despite denying illicit drug usage (Gilligan, C, et al 2021)

ESR- a sed rate will help rule out a MRSA infection as well (Gibbs, D., et al 2022)

Urinalysis- while unlikely a kidney stone or UTI could be causing our patients pain (Meisel, Z, et al 2022)

A .

Differential Diagnoses

Acute disc herniation- our patient presents with pain localized to one side, tenderness and the radiating pain with paresthesia, there is a good case for this being a herniated disc with the paresthesia.

Muscle strain is a very likely diagnosis due to the limited neurological involvement vs

Infection with abscess, possibly MRSA with abscess vs

UTI vs

Kidney stones with atypical presentation

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