NURS 6512 Episodic/Focused SOAP Note Template

Patient Information:

F.P., age 46, Caucasian female
Subjective:
CC: Pain to both ankles, but more concerned about the right ankle
HPI: F.P. is a 46-year-old Caucasian female that presents with bilateral ankle pain. She is more concerned about the right ankle as she heard a “pop” while she was playing soccer over the weekend. She can uncomfortably bear weight to the right ankle. Patient describes the pain as achy and throbbing at times, over the lateral aspect of the right ankle. She currently rates the pain as a 4/10 at rest, and a 7/10 with ambulation. She did elevate and ice the right ankle after the injury. She has taken ibuprofen intermittently for pain relief with moderate results. The pain occasionally radiates approximately 4 inches up the lateral aspect of the right lower extremity. There was immediate swelling to the right ankle after the pop. Her left ankle bothers her at times, with an intermittent pain score of 3-4/10; however, there is no acute change to the left ankle at this time.

Current Medications:

1) Birth control pills
2) Effexor 37.5 mg p.o. daily for depression
3) OTC ibuprofen 600 mg p.o. Q6H prn, pain
Allergies: Denies allergies to drugs, food and latex. Denies environmental allergies.
PMHx: She receives a flu vaccine annually. She has been vaccinated for COVID-19. She received all childhood immunizations appropriately and was last vaccinated with a tetanus booster in 2017.
1) Depression, well-controlled on Effexor
2) C-section x 1
Soc Hx: Patient is married and has one child, age 13. She is a cashier at a local nursery. She was an athletic as a child. She does not smoke, drink, or use recreational drugs. She maintains her health playing soccer with friends and lifting weights 3 x a week. She drinks one cup of coffee daily. Her diet is plant-based. She has been a vegetarian for 10 years.
Fam Hx: Mother is 79, alive and well, with history of severe rheumatoid arthritis, depression, HTN. Father is 82, alive and well, with history of prostate cancer (in remission), mental health disorders (unspecified), HTN, HLD. She has one brother who is 53, alive and well, with “undiagnosed mental health disorders” but it otherwise healthy. Her son, age 13, is healthy. Health history of deceased grandparents include arthritis, colon cancer, prostate cancer, HTN, cirrhosis r/t alcoholism, HLD.
ROS:
GENERAL: Denies weight loss, fever, chills, weakness or fatigue.
HEENT: Denies headaches, changes to vision, hearing, taste, or smell.
SKIN: Denies rash or itching, easy bruising, or poor wound healing.
CARDIOVASCULAR: Denies chest pain, chest pressure or chest discomfort. No palpitations or edema. Denies paroxysmal nocturnal dyspnea and orthopnea. Denies exercise intolerance.
PERIPHERAL VASCULATURE: Denies easy bruising, pain to calves, blood clots, or history of aneurysms.
MUSCULOSKELETAL: Endorses bilateral ankle pain, right greater than left, with swelling to right lateral ankle and difficulty bearing weight. She denies prior joint stiffness, bony deformities, decreased range of motion to bilateral ankles or any other joints.
NEUROLOGIC: Denies history of CVA or TIA, headaches, dizziness, concussion, seizures, weakness, vertigo, numbness and tremors.
MENTAL HEALTH: Reports history of depression which is well-controlled. She reports stable mood. Denies sleep disturbances, irritability, difficulty concentrating, and mood swings.

Objective:

Physical exam:

Vital signs: BP 128/64, HR 70, RR 17, temp 97.9˚F, pulse ox 99% on room air. Height: 5’5”, weight: 123. BMI: 20.5
General: well-developed, well-nourished 46-year-old Caucasian female in mild discomfort related to right ankle pain. She is pleasant and cooperative.
HEENT: Head is normocephalic and atraumatic. PERRLA, EOMI. Sclera anicteric.
Skin: Warm and dry. No noted rashes, wounds, lesions, or excess bruising. There is bruising to right lateral ankle.
Neck: Supple. Full range of motion.
Chest: lungs clear to auscultation. No cough or dyspnea. Heart regular, S1, S2 appreciated without murmurs, rubs, or gallops. No edema noted aside from right lateral ankle.
Peripheral vasculature: Bilateral dorsalis pedis pulses +2, Bilateral posterior tibial pulses +2, bilateral popliteal pulses +2, bilateral femoral pulses +2.
Musculoskeletal System: Right lateral ankle swollen, with decreased range of motion, weakness, and tenderness with palpation to lower aspect of fibula and surrounding ligaments (anterior and posterior tibiofibular ligaments, posterior and anterior talofibular ligaments, and calcaneofibular ligament) as well as lateral malleolus. There is generalized bruising to the lateral aspect of the right ankle. Medial aspect of right ankle non-tender, without bony deformities or bruising. Left ankle without swelling, bruising, overt tenderness with palpation. No noted deformities or decreased range of motion to joints of toes, knees, hands, or fingers. Spine is straight. Patient is able to bear weight on the right foot, with pain. Gait is disturbed due to pain.
Diagnostic results: Right ankle radiograph, if indicated by Ottawa ankle rules; Ankle ultrasound, if indicated; Stress tests to bilateral ankles, if indicated.

Assessment:

Differential Diagnoses:
1) Right ankle inversion sprain
2) Peroneal tendon disorders
3) Chronic ankle instability
4) Ehlers-Danlos syndrome
5) Avulsion fracture of right ankle

Introduction

Ankle injuries constitute a large portion of healthcare visits orthopedic providers, emergency rooms, and urgent care centers. The ankle is highly susceptible to acute injury given its range of motion, high quantity of bones, ligaments, and tendons, and the fact that the ankles bear the weight of the entire body. The structures that could be involved in lateral ankle pain include the anterior and posterior tibiofibular ligaments, anterior and posterior talofibular ligaments, and calcaneofibular ligament, as well as the peroneus longus and peroneus brevis muscles and their tendons, the lateral malleolus, calcaneus, talus, and fibula bones. Damage to these structures from acute muscle strains, ligamental sprains, or fractures, as well as some chronic disorders will be discussed.

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Right Ankle Inversion Sprain

Ankle sprains occur with activity. They range from mild to severe and result from inversion or eversion of the foot. According to Ireland (2017), 19.4% of women’s soccer game injuries are related to the ankle. Our patient was playing soccer when she heard a pop that was followed by pain and difficulty walking. Using the Ottawa Ankle Rules, we can determine if a radiograph is warranted. The Ottawa Ankle Rules were created to eliminate unnecessary ankle radiographs by identifying criteria that could rule out a fracture of the foot or ankle without x-ray (Bachmann et al., 2003). The assessment includes determining if the patient can walk 4 steps immediately after injury, or at the emergency department, and bony tenderness over lateral and medial malleolus, 5th metatarsal, and navicular bones; an ankle x-ray is indicated if the patient cannot bear weight, or there is any bony tenderness (Bachmann et al., 2003). Based on these criteria, and the fact that our patient can walk, albeit painfully, it would not be indicated to assess her ankle via ankle radiograph. Ankle sprains are associated with pain and swelling which this patient endorses. The fact that this patient complains of bilateral ankle pain leads one to consider an acute injury to the right and an underlying disorder of both ankles. This will be discussed further.

Peroneal Tendon Disorders

Due to the patient’s complaints of bilateral ankle pain, other disorders should be considered as an underlying cause. According to Davda et al. (2017), it is often difficult to distinguish a lateral ankle sprain from abnormalities of the peroneal tendons. These tendons run just inferior to the lateral malleolus and along the side of the foot. They attach the tendons of the peroneus longus and peroneus brevis muscles to bones in the lateral aspect of the mid-foot. They function to stabilize the lateral foot and evert the foot (Davda et al., 2017). This group of disorders include tendonitis/tenosynovitis, subluxation and/or dislocation of the tendon, or tendonous tears or splits (Davda et al., 2017). Examination of the ankle and foot should include assessing the lateral ankle ligaments listed above, as well as assessing foot type and palpating the peronei, in conjunction with radiography, MRI and ultrasound to confirm diagnosis (Davda et al., 2017).

Chronic Ankle Instability

Another condition to be considered in this case is chronic ankle instability. If this patient has a history of multiple ankle sprains, her ankles may have become chronically unstable, predisposing her to acute inversion injuries. According to Radwan et al. (2016), a diagnosis can be made if the patient has symptoms of pain, swelling, clinical instability, injury and re-injury, to the lateral aspect of the ankle(s), for greater than 6 months. While this is very common in children and young adult athletes, it can also affect older adults’ quality of life. Arthroscopy, MRI, CT, radiographs, and ultrasounds can be used to diagnose this condition and grade the level of injury (Radwan et al., 2016).

Ehlers-Danlos Syndrome

Ehlers-Danlos syndrome (EDS) is a genetic disorder affecting the connective tissues. If this is suspected, it would be important to question the patient on any history of her family members having similar issues or those described below. There are several subtypes of EDS and thus presentation may be different among patients and difficult to isolate to the syndrome itself. Potential signs include tissue fragility (from easy bruising and impaired wound healing, to GI bleeds and CV events), generalized hypermobile joints (all four limbs and axial skeleton), and hyperextensible skin (excessive stretchiness to skin in three of four areas: distal forearms, neck, knees, dorsum of hands, elbows) (Miller & Grosel, 2020). Further assessment of our patients’ other limb joints and spine would be required as well as examination of skin elasticity. Genetic testing can confirm all subtypes except hEDS (Miller & Grosel, 2020). In addition to measuring the stretch of the skin in the above listed areas, a Beighton score may be calculated to identify generalized joint hypermobility, but there are no other identifying clinical tests to confirm diagnosis (Miller & Grosel, 2020).

Avulsion Fracture

A final differential diagnosis that could be applied to the painful right ankle is an avulsion fracture. This occurs at the sight where a tendon attaches to bone, causing a bone fragment to tear away. The bones that may be affected in the lateral ankle include the lateral malleolus, lateral border of the talus, and 5th metatarsal (Vannabouathong et al., 2018). This fracture can be diagnosed with radiography. The fact that our patient can walk on her injured right foot makes this the least likely diagnosis.

Conclusion

It is likely this patient has sprained her right ankle. Her reports of pain and difficulty walking after playing soccer, during which she heard her ankle pop, makes this the most likely diagnosis. Consideration needs to be taken to the fact that she complained of bilateral ankle pain. This could represent an underlying condition like arthritis, Ehlers-Danlos syndrome, or a peroneal tendon disorder. It is less likely she has an avulsion fracture of the right ankle due to the fact that she can bear weight on the foot.

References

Bachmann, L., Kolb, E., Koller, E., Steurer, J., & ter Riet, G. (2003). Accuracy of Ottawa ankle rules to
exclude fractures of the ankle and mid-foot: systematic review. British Medical Journal, 326,
1-7. doi: https://doi.org/10.1136/bmj.326.7386.417
Davda, K., Malhotra, K., O’Donnell, P., Singh, D., & Cullen, N. (2017). Peroneal tendon
disorders. EFORT Open Reviews, 2(6), 281-292. doi: 10.1302/2058-5241.2.160047
Ireland, M.D., M. (2017, February 1-5). Ankle Injuries: Presentation, work-up, differential diagnosis, and
treatment [Conference session]. ACSM Team Physician Course-Part II: Essentials of sports
medicine: From sideline to the clinic, San Diego, CA, United States.
http://forms.acsm.org/tpc2017/PDFs/10%20Ireland.pdf
Miller, E. & Grosel, J. (2020). A review of Ehlers-Danlos syndrome. Journal of the American
Academy of Physician Assistants, 33(4), 23-28.
doi: 10.1097/01.JAA.0000657160.48246.91
Radwan, A., Bakowski, J., Dew. S., Greenwald, B., Hyde, E., & Webber, N. (2016).
Effectiveness of ultrasonography in diagnosing chronic lateral ankle instability: A
systematic review. International Journal of Sports Physical Therapy, 11(2), 164-174.
Vannabouathong, C., Ayeni, O., & Bhandari, M. (2018). A narrative review on avulsion
fractures of the upper and lower limbs. Clinical Medicine Insights: Arthritis and
Musculoskeletal Disorders, 11, 1-10. doi: 10.1177/1179544118809050