juliet Nnaji
Review of Case study 2
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Episodic/Focused SOAP Note
Patient Information:
JO, 46-year-old female, African American
S.
CC: Pain in both ankles, but more concerned about her right ankle.
HPI: The patient is a 46-year-old African American female who presents to the clinic with complaint of bilateral ankle pain, but more concerned about her right ankle. Patient reports that she heard a pop come from her right ankle while playing soccer 3 days ago over the weekend, and ever since her right ankle has become increasingly uncomfortable. She is able to bear weight but it is uncomfortable when standing or walking. Patient described the pain as a dull uncomfortable pain and she rates the pain as 7/10 to the right ankle and 3/10 to the left ankle. She believes that the right ankle is bruised and swollen. She reports that she takes Ibuprofen and Tylenol alternately for pain and swelling and it makes it tolerable. Pain is aggravated whenever she puts weight on it to stand or walk but feels better when she is seated with her right foot raised.
Current Medications:
Ibuprofen 600mg every 8 hours as needed for the pain
Tylenol 1000mg every 4 hours as needed for pain
One-A-Day Women’s Multivitamins one tablet daily
Ferrous Sulfate 325mg once daily
Allergies: Denies any drug, food, latex or seasonal allergies
PMHx: Osteoarthritis (diagnosed 7 years ago), Type 11 DM and HTN (diagnosed 3 years ago). Right total knee replacement (3 years ago). Received influenza vaccine this season, Current on Covid and other vaccines. Last Tdap 11/25/2020. No recent hospitalizations
A.
Differential Diagnoses
1)Primary Diagnosis is Ankle Sprain:
An ankle sprain is an injury to one or more ligaments in the ankle with symptoms such as pain, swelling, soreness, bruising, limited range of motion and joint stiffness (Dains, Baumann, & Scheibel, 2019). It is an inversion-type twisting of the foot, followed by pain and swelling (Young, 2019). This type of injury is often associated with physical activities or sports. Sports injuries occur when running, cutting, landing from a jump, or from direct contact which can produce an audible tear or pop causing pain and swelling that are immediate, but ecchymosis may lag a day or two behind (American Orthopedic Foot & Ankle Society, 2021). JO has most of these symptoms and is able to bear weight which rules out a more complex structural injury or fracture.
2) Bursitis: Bursitis can be described as the acute or chronic inflammation of a bursa that results in localized pain, tenderness, and swelling over the bursa (Maffulli, et al, 2018). Other symptoms that are associated with this condition is low-grade temperature, the warmth of overlying skin, and a palpable bump over heel (Maffulli et al., 2018).
3) Plantar fasciitis: This affects women twice as often as men. It is caused by chronic weight-bearing stress when laxity of the foot structures allows the talus to slide forward and medially, calcaneus to drop, and plantar ligaments and fascia to stretch (Dains, et al., 2019). Pain is worse on awakening and is relieved with non-weight bearing activity, often involving the heel (Baumann, et al., 2016).
4) Ankle Fracture: An ankle fracture produces diffuse swelling surrounding the injured bone immediately following injury (Dains et al., 2019). In some cases of a fracture, a visible deformity can be observed on inspection if the fracture is displaced. This can be ruled out as JO heard a popping sound with the injury and is weight bearing.
5) Achilles tendon ruptures: An Achilles tendon rupture can parallel symptoms associated with ankle sprains. An Achilles tendon rupture should be suspected if the patient experiences an extensive amount of swelling, bruising or pain (Young, 2019). Furthermore, swelling associated with a ligament rupture occurs within minutes of the injury.
References
American Orthopaedic Foot & Ankle Society (2021). Ankle Sprains While Running: Symptoms and Treatment. https://www.aofas.org/news/press-releases/2021/08/19/ankle-sprains-while-running-symptoms-and-treatment
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.
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
Maffulli, N., Longo, U. G., &Denaro, V. (2018). Bursitis. Retrieved from https://online.epocrates.com/diseases/52311/Bursitis/Key-Highlights
Young, C. (2019). Medscape: Ankle sprain. Retrieved from https://emedicine.medscape.com/article/1907229-overview
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Tokunbo Allen
Allen’s wk 8 discussion main post
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Episodic/Focused SOAP Note for Case One
Patient Information:
- M., 42 years old, male, Caucasian
S.
CC: “Lower Back Pain that sometimes radiates to his left leg.”
HPI: Mr. J.M., a 42-year-old Caucasian male, complains of lower back pain that began about a month ago. He claims that occasionally the pain radiates to his left leg. Long durations of standing or sitting make his lower back pain worse. He denies experiencing any fever, chills, or sweating.
Location: Lower back
Onset: One month ago
Character: Sharp pain in his lower back that sometimes radiates to his left leg.
Associated signs and symptoms: None
Timing: The lower back pain started one month ago, and long durations of standing make the pain worse.
Exacerbating/ relieving factors: Long durations of standing
Severity: 7/10 pain scale
Current Medications:
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Diagnostic result
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- Patient history and physical exam. It is essential in assessing differential diagnosis such as caudia equina.
- Have the patient walk across the room to examine abnormalities in their gait (pattern of walking (Dains et al., 2019).
- Perform hip flexion and knee hyperextension up to 30 degrees.
- Bend or flex parts of the patient’s spine to assess a spinal range of motion example, bend forward (Dain et al., 2019).
- Have the patient simply stand to identify any problems with balance, posture and/or spinal alignment
- Perform CBC and urinalysis. This test is used to confirm the diagnosis of infection or malignancy. According to Forster and Wang (2020), symptoms like back pain can prompt a care provider to conduct a urinalysis test.
- Conduct plain-film x-ray. They offer a view of motion and evidence of trauma. X-rays and imaging studies are generally used to confirm a patient’s symptoms and exam results to identify the source of pain (Jenkins et al., 2018).
- Perform a CT scan. An x-ray of the spinal canal gives a good definition of the bone. It helps detect abnormal tissue and the state of the patient’s spine. Structural abnormalities are commonly identified by CT and MRI in patients complaining of low back pain (Rao et al., 2018). If the condition is secondary to bone collapse from trauma or cancer, this study can help define that. Visualization of the discs is not as easily seen on CT scans. If no MRI is available, this study can give information helpful in evaluating the anatomy of the region, particularly if done in combination with a myelogram described below.
- Myleogram. It is an X-ray of the spinal canal following the injection of contrast material into the surrounding cerebrospinal fluid spaces; can show displacement on the spinal cord or spinal nerves due to herniated discs, bone spurs, and tumors (American Association of Neurological Surgeons, n.d.).
- Magnetic resonance imaging (MRI). It is a diagnostic test that produces three-dimensional images of body structures using magnetic fields and computer technology. MRI produces images of the spinal cord, nerve roots, and surrounding areas (American Association of Neurological Surgeons, n.d.).
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Lumbosacral Herniated Disc. If a disc herniates and leaks some of its inner material, it can swiftly shift to aggravating a nerve from easing daily life, resulting in back pain and perhaps pain and nerve symptoms down the leg. According to Dydyk et al. (2021), a herniated disc in the spine is a condition during which a nucleus pulposus is displaced from intervertebral space, and it is a common cause of back pain. This might be related to activities that involve carrying big objects, such as lifting weights, which the patient engages in often. An acute low back ache that travels down the buttock and below the knee is brought on by a herniated disc, which also irritates the nerve roots.
Musculoskeletal Lumbar Strain. The majority of low back pain episodes are caused by injuries to the muscles, tendons, and ligaments that support the lower spine (Parfenov et al., 2018). The lumbar spine is supported by the hip, pelvic, buttock, hamstring muscles, and low back muscles. Pain or tightness across the low back and into the hips or buttocks may be experienced when these muscles are damaged. Excessive stretching or a forceful contraction that exceeds the muscle’s function ability might result in such a strain. This can be related to a poor exercise warm-up.
Lumbar Stenosis. Spinal stenosis happens when the spaces in the spine narrow and create pressure on the spinal cord and nerve roots (Bagley et al., 2019). The spinal cord is a bundle of nerves that comes out of the base of the brain and runs down the center of the spine. It comprises four regions, cervical spine, thoracic spine, lumbar spine, and sacrum and coccyx, which work together to support the body. The narrowing usually occurs over time and involves one or more areas of the spine. The patient is 42 years old, making age a factor. Symptoms of spinal stenosis may develop when the spaces within the spine narrow, most often in the lower back and neck. The narrowing creates pressure on the spine and related structures, causing symptoms. For most people, symptoms develop and progress slowly over a period of time, and some people may not have any symptoms. The symptoms experienced by a patient depend on the location of the narrowing in the spine. Symptoms of spinal stenosis in the lower back can include lower back pain. The second is a burning pain or ache that radiates down the buttocks and into the legs, which typically worsens with standing or walking and gets better with leaning forward (flexion) (Bagley et al., 2019). The other is numbness, tingling, or cramping in the legs and feet. These may become more pronounced during standing or walking. Lastly, the patient may experience weakness in the legs and feet.
Spondylolisthesis. Spondylolisthesis is a spinal condition that causes lower back pain. It occurs when one of a person’s vertebrae, the bones of the spine, slips out of place onto the vertebra below it. Spondylolisthesis has no neurological signs, but the pain is localized to the lower back. Other symptoms include muscle tightness and stiffness, pain in the buttocks, pain spreading down the legs due to pressure on nerve roots, pain that gets worse with activity, tight hamstrings, and trouble standing or walking (Evans & McCarthy, 2018).
Cauda Equina. According to the American Association of Neurological Surgeons (n.d.), Cauda Equina compression of the S1 nerve root produces continuous lower back pain with saddle distribution of anesthesia. The patient will present with symptoms including lower back pain, unilateral or bilateral sciatica nerve pain, bowel and bladder disturbances, generally present with BB incontinence, lower extremity motor weakness with limping, sensory losses or deficits in the lower extremity, and reduced or absent lower extremity reflexes.
References
American Association of Neurological Surgeons (n.d.). Cauda equina syndrome. Retrieved from https://www.aans.org/en/Patients/Neurosurgical-Conditions-and-Treatments/Cauda-Equina-Syndrome
Bagley, C., MacAllister, M., Dosselman, L., Moreno, J., Aoun, S. G., & El Ahmadieh, T. Y. (2019). Current concepts and recent advances in understanding and managing lumbar spine stenosis. F1000Research, 8(137), 137.
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.
Dydyk, A. M., Massa, R. N., &Mesfin, F. B. (2021). Disc herniation. In StatPearls [Internet]. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6118107/
Evans, N., & McCarthy, M. (2018). Management of symptomatic degenerative low-grade lumbar spondylolisthesis. EFORT Open Reviews, 3(12), 620-631.
Forster, C. S., & Wang, J. (2020). Symptom-and urinalysis-based approach to diagnosing urinary tract infections in children with neuropathic bladders. Pediatric Nephrology, 35(5), 807-814.
Jenkins, H. J., Downie, A. S., Moore, C. S., & French, S. D. (2018). Current evidence for spinal X-ray use in the chiropractic profession: a narrative review. Chiropractic & Manual Therapies, 26(1), 1-11.
Parfenov, V. A., Yakhno, N. N., Kukushkin, M. L., Churyukanov, M. V., Davydov, O. S., Golovacheva, V. A., &Shirokov, V. A. (2018). Acute nonspecific (musculoskeletal) low back pain Guidelines of the Russian Society for the Study of Pain (RSSP). Neurology, Neuropsychiatry, Psychosomatics, 10(2), 4-11.
Rao, D., Scuderi, G., Scuderi, C., Grewal, R., & Sandhu, S. J. (2018). The use of imaging in the management of patients with low back pain. Journal of Clinical Imaging Science, 8(2), 30-30.
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