Focused SOAP notes for a patient with ankle pain

Posted: February 15th, 2023

Week 8 dicussion on Knee Pain

Focused SOAP notes for a patient with ankle pain

S

CC: Ankle Pain

HPI: This patient is a 15-year-old male who presents with bilateral ankle pain with a clicking noise in one or both knees sometimes. The patient describes a catching sensation under the patella.

PMH: Twisted right ankle in a fall in a soccer game 3days ago.

FH: Mother is a school teacher, the father is a football coach diagnosed with type 2 DM at

35 years of age. Like to play football and a staunch fan of Redskins.

ROS:

General- Negative for fever, chills, fatigue.

Cardiovascular- Negative for orthopnea, S1S2 head, no murmurs, right ankle

swearing.

Gastrointestinal- ABD soft non-tender, negative for nausea, vomiting, and diarrhea.

Pulmonary- no breathing difficulties, negative for coughing.

O

V/S: T-97.1, P-69, R-17, B/P- 124/78, O2 SAT- 97%, WT-124, HT-6ft

General: the patient is calm and cooperative.

Cardiovascular: PMI at 5th intercostal space at mid-clavicular line. Right knee minimally

swollen with pain rated at 6/10. Slightly limited mobility. Admits a cracking sound

during fall. No cynosis, full pulses.

Gastrointestinal: abdomen soft, non-tender, B/sounds positive in all quadrants.

Pulmonary: breathing even, no distress.

Diagnostic results:

X-ray of the right knee- negative
MRI of right tendons- Irritations of the patella
CT scan of the knee.

Differential diagnosis:

1. Rheumatoid arthritis( RA)-a chronic systemic autoimmune inflammatory disease characterized by aggressive symmetric inflammation of multiple joints. Although this patient has minimal swelling to the right knee only, it is not chronic and does not relate to increase Body Mass Index as well as in the case of RA, hence it is ruled out.

2. Osteoarthritis (OA)- degenerative joint disease results from deterioration of the cartilage of bones causing inflammation, swelling, pain in affected joints, and eventual stiffness and mobility limitation (Stark & Price, 2019). Although there is pain and swelling to the right knee of this patient, this is not due to old age, joint overuse, previous joint injury, etc as in OA, hence OA is ruled out.

3. Knee fracture: The fracture of the knee joint area is one of the severe limb bone injuries.Vakhitov et al.(2018).

Knee sprain- refers to injuries, defects, or disorders of muscles of the body caused by injury, over-exercise, disease, toxin, endocrine, neurological and hereditary factors . Common muscular disorders are those resulting from overexertion, exercise, athletics, accidents, trauma, etc which form a classic example of patient under discussion.
Patella tendonitis-Injury to the tendon connecting the kneecap(patella) and the Tibia

The diagnostic performance characteristics of MRI, CT, bone scintigraphy. Identifies true fractures among suspected scaphoid fractures. Calculated sensitivity and specificity with latent class analysis are different with reference to traditional based calculations of CT in the scaphoid planes(Buijze et al.2011).

Sprain causes minimal to moderate pain increasing 1 to 2 days after the traum awhen the inflammatory process begin(Dains et al.2019).

References:

Stark, W. & Price, V. (2019). Osteoarthritis Magill’s medical guide (online edition).Retrieved from https://search-ebscohost-com.ezp.waldenulibrary.org/login.aspx?direct=true&db=ers&AN=86194360&site=eds-live&scope=site.

Buijze, Geert A.; Mallee, Wouter H.; Beeres, Frank J. P.; Hanson, Timothy E.; Johnson, Wesley O.; Ring, David. CLINICAL ORTHOPAEDICS AND RELATED RESEARCH. 469 (12) ,p3400-p3407.

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

Vakhitov, I., Pankov, O., Vakhitov, K.,Nagmatullin,R.&Vakhitov,I.(2018).Our experience of patient treatment with knee fractures:A case report.Drug Intervention Today.10,3188-3192.Retrieved from http://search-ebscohost-com.ezp.waldenulibrary.org/login.aspx?direct=true&db=a9h&AN=133549289&site=edslive&scope=site