Episodic/Focused SOAP Note Template Assignment Paper

Episodic/Focused SOAP Note Template Assignment Paper

Episodic/Focused SOAP Note Template Assignment Paper

APA format 3 peer references needs to review case study and document on differential diagnosis as to agreeing or disagreeing  Due October 20.2018 at 5pm

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Episodic/Focused SOAP Note Template

Patient Information:

A.S., 46 F, Caucasain

S.

CC “ankle pain in both ankles; worse in right ankle, after hearing ‘pop’ while playing soccer.”  Episodic/Focused SOAP Note Template Assignment Paper

HPI: A.S. is a 46 year old Caucasian female who presents with bilateral ankle pain which she describes as chronic for the last 3 months. She acutely injured her right ankle 3 days ago while playing soccer. The pain is described as aching with intermittent sharp characteristics. Associated symptoms include limited ROM. The pain is worse with weight bearing and OTC pain medications have included alternating doses of Tylenol and Motrin with moderate relief.

Current Medications:

            Motrin 200 mg by mouth every 4-6 hours as needed for pain

Hydrochlorothiazide 12.5mg by mouth daily for 6 months for HTN  Episodic/Focused SOAP Note Template Assignment Paper

Allergies: PCN- rash, no known food/environmental allergies

PMHx: HTN; immunizations are up to date- last tetanus 12/2017; flu shot 10/2018 cholecystectomy 2015

Soc Hx: A.S. is employed as a Registered Nurse and remains active by playing soccer three times a week. She is married with two teenage daughters. She denies tobacco and alcohol use.

Fam Hx: Maternal grandmother deceased at age 56 from MI. Maternal father deceased at age 75 from complications of COPD. Paternal grandparents unknown. Father history is unknown. Mother is alive with type 2 diabetes that is well controlled with oral agents. Sibling age 43 alive and well. Children are alive and well with no medical hx.  Episodic/Focused SOAP Note Template Assignment Paper

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:  No burning on urination.

NEUROLOGICAL:  No headache, dizziness, syncope, paralysis, ataxia, numbness or tingling in the extremities. No change in bowel or bladder control.

MUSCULOSKELETAL: pain and swelling to right ankle, limited weight bearing and ROM in b/l ankles, worse in the right ankle. No muscle cramping.  No back pain.  Episodic/Focused SOAP Note Template Assignment Paper

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.

O.  Episodic/Focused SOAP Note Template Assignment Paper

GENERAL:  AAOx 3, limping gait, no distress. No fever.  Skin is warm, dry, and intact. Skin of the lower extremities is warm and pink in color.

CARDIOVASCULAR: chest is symmetric with symmetrical expansion, PMI noted at fifth intercostal space at the midclavicular line, normal S1 and S2, no m/r/g, no edema in legs, dorsalis pedis 2/4 bilaterally, normal hair distribution in legs and no pigmentation of b/l legs.

MUSCULOSKELETAL: limited ROM and weight bearing in b/l ankles, worse in right ankle. No clubbing, cyanosis, or edema.

NEUROLOGICAL: mood and affect appropriate, CN II-XII intact. Motor: 5/5 in upper and lower extremities, DTRs 2+ bilaterally.

Diagnostic results:

Ankle x-ray- If the Ottawa ankle rule is positive (bone tenderness at posterior malleolus, bone tenderness at posterior medial malleolus, or inability to bear weigh > 4 steps) ankle radiographs are indicated (Polzer, Kanz,  Prall, Haasters, Ockert, Mutschler, & Grote, 2012).  Episodic/Focused SOAP Note Template Assignment Paper

If ankle radiographs negative- assess ligament in affected extremity as compared to un-injured extremity by doing the crossed leg test, squeeze test, external rotation test, anterior drawer test, and talar tilt test. These tests will assist in determining the need for an MRI and also grading the sprain  (Polzer, Kanz,  Prall, Haasters, Ockert, Mutschler, & Grote, 2012).

Labs may include a uric acid level which is elevated with gout and a WBC which would be elevated with  osteomyelitis. MRI imaging may also be indicted.

A.

Sprain- because the patient heard the “pop” sound, her injury is likely related to an ankle sprain in which the ligaments and tissue that surround the bones of the ankle are injured causing swelling, pain, and limited ROM  (PubMed Health, 2018).

Fracture- a fracture would be unlikely if the patient was able to bear weight after the injury. The area would also become ecchymotic with limited to no ROM (PubMed Health, 2018).

Osteomyelitis- the extremity would be warm, erythematous, not usually associated with an acute injury, potential fever present, usually associated with a systemic infection or a wound (Ball, Dains, Flynn, Solomon, & Stewart, 2015)

Gout- associated with hot, swollen joints, pain and limited ROM (Ball, Dains, Flynn, Solomon, & Stewart, 2015)

Bursitis- limited ROM, swelling, pain, warmth, and point tenderness (Ball, Dains, Flynn, Solomon, & Stewart, 2015)

References

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2015). Seidel’s guide  to physical examination (8th ed.). St. Louis, MO: Elsevier Mosby.

Polzer, H., Kanz, K. G., Prall, W. C., Haasters, F., Ockert, B., Mutschler, W., & Grote, S. (2012).

Diagnosis and treatment of acute ankle injuries: development of an evidence-based algorithm. Orthopedic Reviews, 4(1), e5. http://doi.org/10.4081/or.2012.e5

PubMed Health. (2018). Ankle sprains: overview. Retrieved from

https://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0072736/  Episodic/Focused SOAP Note Template Assignment Paper

 

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