Focused SOAP Note/case study CC: “Pain in both my ankles”

Posted: February 15th, 2023

Discussion – Week 8

Focused SOAP Note/case study

Patient Information

Initials: C.M.M, Age: 46, Sex: Female, Race: White

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CC: “Pain in both my ankles”

HPI: CMM, a 46-year old white female reports pain in both of her ankles that started two days ago. She is more concerned about her right ankle and she describes a “pop” sound she heard while she was playing soccer over the weekend. Although she can bear weight, she explains that she has been feeling uncomfortable ever since the soccer game. The patient has expressed temporary relief when she placed a bag of ice over her ankle, and she expresses the severity of pain on the scale of one-ten as a four.

Current Medication: Insulin injections: U-100 insulin 3 times a day, 30 minutes before a meal and U-500 insulin 3 times a day, 30 minutes before a meal. The patient has been receiving this treatment for the past 4 years as an intervention for type 1diabetes. The patient also uses Aspirin for occasional headaches.

Allergies: CMM is lactose intolerant thus does not consume dairy products.

PMHx: Immunized for influenza and received tetanus, diphtheria, and acellular pertussis (Td/Tdap) vaccination. The last date of the tetanus vaccination is 14/07/2016. CMM has a 4-year history of type 1 diabetes, but no history of past surgical procedures.

Soc Hx: CMM is self-employed and works from her home office. She is a mother of four and a wife who loves gardening, cycling and spending time with her family. She denies any tobacco or drug use. She admits to previously drinking three or four glasses of wine in a day which she adjusted to a glass or two after a diabetes diagnosis. Asked whether she fastens her seatbelt every time she drives, she nodded and said “yes’. CMM lives in a secure, middle-class neighborhood, where houses come with working security systems and smoke detectors. CMM says that her family is the most supportive element in her life.

Fam Hx: CMM reported a family history of diabetes. Sullivan (2019) describes it as important to check for family history for diseases with genetic tendencies such as diabetes, whilst presenting any first-degree relatives currently or previously suffering from the same conditions to determine the cause of illness. Her grandfather died in the Second World War, while her grandmother died from diabetes. Her father died from diabetes and she lost her elder brother in a robbery two years ago.

ROS:

GENERAL: Relaxed and pleasant 46-year old white female that acknowledges experiencing slight weight gain and occasional fatigue.

HEENT: Head normocephalic, blurred vision, no hearing loss, nose congestion or sore throat.

SKIN: Little bumps on insulin injection sites.

CARDIOVASCULAR: No chest pain or chest discomfort. Reports heart palpitations during vigorous activities.

GENITOURINARY: Frequent urination. No burning sensation during urination. Last Menstrual period: 10/27/2018.

NEUROLOGICAL: Reduced bladder control.

MUSCULOSKELETAL: Ankle pain and a “pop” sound from the right ankle

ENDOCRINOLOGIC: Reports of sweating, polyuria, and polydipsia.

ALLERGIES: Lactose intolerant.

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Physical Exam:

A physical exam was carried out by palpating the client’s ankle joints. Dains, Baumann, and Scheibel (2019) recommend the examination of the ankle joints by touching the ligaments’ points of attachment and course is important in helping one trace the pressure points and sources of discomfort. Slight tenderness was felt at the joint, however, CMM complained of no inflammation. A Range of Motion Exercises (ROM) is part of special maneuvers carried during the physical exam. Dains et al. (2019) explain that ROM exercises help determine the state of the joint ligaments. A pop sound was heard at the ankle joint during these exercises. LeBlond, Brown, and DeGowin (2014) describe that the tibia and the talus of the foot are the bones that articulate the movement at the joint with the help of various fibular ligaments. The Ottawa ankle rules are necessary to determine the cause of CMM’s discomfort before determining the necessity of an ankle x-ray. Stiel (n.d) emphasizes the importance of not ignoring malleolar tenderness, which may warrant an x-ray procedure if a patient cannot bear weight. However, since CMM can bear weight, an x-ray procedure is not necessary.

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Differential Diagnosis:

Inversion Ankle Sprain

The most likely diagnosis is an inversion ankle sprain. Dains et al. (2019) argue that this type of ankle sprain results from an inversion force stressing joint ligaments, thus the “pop” sound that is audible. Dains et al. (2019) explain that people suffering from ankle sprains can bear weight on the injured ankle despite discomfort. This fits CMM’s case.

Achilles tendinitis

Another likely diagnosis in CMM’s case is Achilles tendinitis. Dains et al. (2019) describes that the inflammation of the Achilles tendons creates discomfort and a feeling of tightness of the tendon. Tenderness of the Achilles tendons on palpation and the use of ROM exercise as a way to reach to the diagnosis is a way to establish the integrity of the Achilles tendons, thus arriving at a sure diagnosis.

Plantar fasciitis

Plantar fasciitis is another likely diagnosis. Dains et al. (2019) explain that this problem affects women twice as often as men and is caused by weight-bearing stress and is characteristic of heel pain or discomfort. However, as the patient complains of no weight-bearing stress, the likelihood of CMM’s case being of plantar fasciitis is unlikely.

References

Dains, J. E., Baumann, L. C., & Scheibel, P. (2019). Advanced health assessment and clinical diagnosis in primary care (6th ed.). St. Louis, MO: Elsevier Mosby.

LeBlond, R. F., Brown, D. D., &DeGowin, R. L. (2014). DeGowin’s diagnostic examination (10th ed.). New York, NY: McGraw Hill Medical.

Stiel, I. (n.d). The Ottawa Ankle Rules. Retrieved from http://www.theottawarules.ca/ankle_rules.

Sullivan, D. D. (2019). Guide to clinical documentation (3rd ed.). Philadelphia, PA: F. A. Davis