SOAP Note : Ankle Pain

EXAMPLE: Ankle Pain
Note: Rather than the traditional narrative Discussion posting format, your Discussion post should be in the SOAP Note format. For more information, see the Comprehensive SOAP Template in the attachments below.
SOAP Note: Ankle Pain: A 46-year-old female reports pain in both of her ankles, but her right ankle is more concerned. Over the weekend, she was playing soccer when she heard a “pop.” She can bear weight, but it is painful for her. What foot structures are likely to be involved in determining the cause of ankle pain based on your knowledge of anatomy? What other symptoms should be investigated? What are your possible diagnoses for ankle pain? What kind of physical examination will you conduct? What special moves are you planning? Should you use the Ottowa ankle rules to see if you need more testing?
Patient Information: CC
A 46-year-old woman complains of pain in both ankles, but is especially concerned about her right.
She was playing soccer over the weekend when she heard a “pop.”
She can support weight, but it is inconvenient.
Based on your knowledge of anatomy, which foot structures are most likely to be involved in determining the cause of ankle pain?
What other symptoms should be looked into?
What is your differential diagnosis for ankle pain?
Which physical examinations will you perform?
What unusual movements do you have in mind?
Should you apply the Ottowa ankle rules to determine whether additional testing is required?
Initials, Unknown Age, 46 Sex, Female Race, Unknown
CC: Ankle pain on both sides
Pt c/o bilateral ankle pain, which worsened on R after hearing a “pop” while playing soccer this weekend.
Pt can bear weight, albeit with difficulty, and was more concerned about her right ankle.
Both sides of the ankles
Beginning: Over the weekend
Ankle pain on both sides, with the right being the worst.
She was playing soccer over the weekend when she heard a “pop.”
She can bear weight, but it is painful for her.
I heard a “pop” over the weekend while playing soccer.
Factors that aggravate/relieve: She can bear weight, but it is painful.
Seriousness: She can bear weight, but it is painful for her.
Medications currently being taken:
Unspecified
There were no mentions of allergies.
PMHx: None were found.
Soc Hx: I played soccer over the weekend.
There is no indication for Fam Hx.
There is no evidence of weight loss, fever, chills, weakness, or exhaustion.
HEENT: PERRLA, no hazy vision, double vision, or yellow sclerae.
There is no evidence of hearing loss, sneezing, congestion, a runny nose, or a sore throat.
There is no sign of a rash, itching, or discoloration on the skin.
CARDIOVASCULAR: There is no pain, pressure, or SOB in the chest.
Palpitations or edema are not present.

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There is no evidence of shortness of breath, coughing, or difficulty breathing.
GASTROINTESTINAL: Anorexia, nausea, vomiting, or diarrhea are not present.
There are no signs of stomach pain or blood.
GENITOURINARY: There is no burning when urinating.
There is no indication of pregnancy.
The previous month’s menstrual cycle is not provided.
There are no signs of a headache, dizziness, syncope, paralysis, ataxia, numbness, or tingling in the extremities.
There is no evidence of bowel or bladder control change.
MUSCULOSKELETAL: bilateral ankle pain, worse on the right. MUSCULOSKELETAL: pain in both ankles, worse on the right.
Positive pulses on the dorsalis and pedis bilaterally.
Right ankle has 1+ edema, erythema, and palpable pain.
There was no evidence of edema or erythema on the left ankle.
HEMATOLOGICAL: Anemia, bleeding, or bruising are not present.
LYMPHATICS: No lymph nodes are swollen.
There is no prior splenectomy history.
PSYCHIATRIC: There were none mentioned.
ENDOCRINOLOGICAL: There have been no reports.
ALLERGIES TO NkDA
Peripheral Vascular: 1+ edema, erythema, and palpable soreness in the right ankle.
There is no evidence of edema or erythema on the left ankle.
Positive pulses on the dorsalis and pedis bilaterally.

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Assessment:
Further inquiries
Additional questions could include the following:
Can you pinpoint the source of your discomfort?
On a scale of 0 to 10, how would you rate your pain, with 0 being no discomfort and 10 being the worst?
Have you tried anything to help with your pain?
What factors influence its improvement or deterioration?
X-rays, computed tomography scans, and magnetic resonance imaging will be used to make a diagnosis (MRI).
An ankle x-ray should be performed if pain is present in the malleolar area at one of the following locations: bony tenderness to the distal 6cm of the posterior edge or tip of the lateral malleolus, bony tenderness to the distal 6cm of the posterior edge or tip of the medial malleolus, or the patient is unable to bear weight, according to Ball, Dains, Flynn, Solomon, and Stewart (2015).
The Ottawa Ankle Rules, according to Ball, Dains, Baumann, and Scheibel (2016), are used to determine whether a patient with ankle pain requires diagnostic testing.
If a patient has ankle discomfort in the malleolar area, bone tenderness near the posterior fibula, bone tenderness near the posterior tibia, or the inability to bear weight for four steps, he or she should be referred for an ankle radiography series, according to this tool.
Furthermore, Ottawa has a fracture detection sensitivity of 98.5 percent.
Various Diagnosis
1. Ankle Sprain is defined as an injury to one or more ankle ligaments that results in pain, swelling, bruising, discomfort, joint stiffness, and difficulty walking.
While running, landing a jump, or making any direct contact that causes discomfort, swelling, and possibly audible tearing or popping, ecchymosis can be delayed by a few days (American Orthopedic Foot & Ankle Society, 2015).
Achilles tendon injury: Caused by a sudden snap in the lower calf, resulting in inability to stand on the toes of the affected side (Saglimbeni, 2016).
Muscle soreness after exercise is characterized by discomfort or pain in the distal region of skeletal muscles, as well as decreased strength and flexibility (Kedlaya, 2016).
Achilles tendon injury causes a snap in the lower calf and the inability to stand on the toes of the affected side (Saglimbeni, 2016).
5. Ankle Fracture: The calcaneus, navicular, and metatarsal bones are the most commonly fractured in the foot, with the cuboid bone being the least frequently fractured.
Swelling, bruising, and the inability to bear weight are common symptoms of an ankle fracture (Unnithan & Thomas, 2018).
References
The Orthopedic Foot and Ankle Surgeons Society of the United States of America
(June 2015).
Ankle sprain.
The original can be found at http://www.aofas.org/PRC/conditions/Pages/Conditions/Ankle-Sprain.aspx.
Foot and Ankle Surgeons College of the United States of America (2018).
Ankle sprain.
The Foot Health Facts website can be found at https://www.foothealthfacts.org/conditions/ankle-sprain.
R. W. Stewart, J. W. Ball, J. E. Dains, J. A. Flynn, B. S. Solomon, and J. W. Ball (2019).
Seidel’s
A multidisciplinary approach to physical examinations (9th ed.).
Mosby, Elsevier, St. Louis, MO.
Kedlaya, D. (2016).
Muscle Soreness After Exercise
The original can be found at http://emedicine.medscape.com/article/313267-overview#a4.
J. Kelly (2015).
Ankle fractures are common in sports medicine.
http://emedicine.medscape.com/article/85224-clinical#b4 Archived from the original on
A. Luke (2011).
Ankle Physical Examination
Institute of Orthopaedics and Traumatology
https://orthosurg.ucsf.edu/oti/patient-care/divisions/sports-medicine/physical-examination-information/ankle-physical-examination/

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Student paper example
Citing Sources
The Writing Center is a great resource

To get ready:
Concerning the case study you were assigned:
Examine this week’s Learning Resources and think about the insights they provide about the case study.
Consider what information you would need to obtain from the patient in the case study you were assigned.
Consider what physical exams and diagnostic tests would be necessary to learn more about the patient’s condition. How would the findings be used to make a decision?
Identify at least five possible conditions that could be considered in the patient’s differential diagnosis.
Address all of these in the SOAP Note, not the Narrative Essay (use the SOAP Note Template attached):
1. A description of the health history you will need to obtain from the patient in the case study to which you have been assigned.
2. Describe the appropriate physical exams and diagnostic tests, as well as how the results will be used to make a diagnosis.
3. Explain why you chose each of the five possible conditions for the patient’s differential diagnosis.
4. Explain how the patient’s X-ray (attached) helped you narrow down the differential diagnosis.
5. Please answer all of the questions about the case in the SOAP note.

PLEASE MAKE A SOAP NOTE FOR THIS CASE. Create your own patient data, applicable health history, system review, P.E., labs, differential diagnosis, final diagnosis, and so on. Incorporate the case data into the SOAP note that you will create… Okay, this isn’t a narrative essay…. I require a SOAP note (a SOAP note is created by a Nurse Practitioner/RN/MD)… Follow the SOAP Note in the templates/exemplar… Do not copy and paste. Create your own… Remember to include citations for the five different possible conditions (Differential diagnosis) as well as reference lists.

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SOAP Note : Ankle Pain