Focused SOAP Note for a patient with ankle pain: the patient is a 46-year-old woman who came to the clinic with the chief complaint of ankle pain, notably in her right ankle. She reported hearing a \”pop\” sound while playing soccer over the weekend. Pt can bear weight, but with some pain. She has not yet sought pain relief treatment.
Name: RN Gender: female Age: 46 Race: Caucasian
CC: “I feel a lot of pain in my ankle, particularly the right ankle.”
HPI: the patient is a 46-year-old woman who came to the clinic with the chief complaint of ankle pain, notably in her right ankle. She reported hearing a \”pop\” sound while playing soccer over the weekend. Pt can bear weight, but with some pain. She has not yet sought pain relief treatment.
Allergies: She did not report any drug/ food allergies
PMH: None reported
PSH: None reported
Social History: None provided
Significant Family History: None provided
Lifestyle: She reported taking part in soccer during the weekends
Additional questions for the patient: Can you pinpoint the location of your pain? On a scale of 0 to 10, where 10 is the worst agony you\’ve ever experienced, how would you evaluate your pain? Is there anything that makes the pain go away or get worse? When did all of this start? What were you doing when you heard the \”pop,\” sound? How long have you been battling ankle pain? Do you have a history of ankle injuries?
Constitutional: Denies fever and exhaustion, as well as trouble bearing weight on the right ankle during ambulation.
CV: Not provided
GI: Not provided
MSK: bilateral ankle discomfort with increased right ankle discomfort while ambulating.
Psychiatric: Not provided
Skin: Not provided
Endocrine: Not provided
Vital signs: not provided
1. Primary diagnosis: Ankle sprain: Athletes are highly vulnerable to ankle sprains, and they typically present with pain after a notable injury, but with the capacity to bear weight, perhaps with some pain(Miklovic et al., 2018).
2. Ankle fracture: The most typical signs of an ankle fracture include throbbing pain with incapacity to ambulate, as well as bruising, edema, and difficulty bearing weight.
3. Achilles tendon injury: The injury causes pain above the heel, especially when the ankle is stretched when standing. It might be minor at first and become better or worse with time. When a tendon ruptures, the pain is instantaneous and intense (Lemme et al., 2018).
4. Navicular fracture: This form of the fracture causes navicular discomfort to the dorsum of the heel, often medially along the arch, which intensifies with physical exercise.
5. Post-exercise muscle soreness: This type of injury manifests as pain in the distal region of muscle tissue following unfamiliar physical exercise, as well as an impaired range of motion (Afonso et al., 2021).
PLAN: Considering the patient has an ankle sprain, I will recommend RICE therapy with a follow-up appointment in a few weeks (Calin et al., 2019).
The lateral ankle complexity is most often affected because it is more susceptible to the typical inversion-type twist of the ankle, but the distal tibia, fibula, and talus bone must also be evaluated because they are the critical parts of the ankle joint (Singh et al.,2018). I will visually evaluate and palpate the bilateral lower limbs for any deformities, as well as examine the distal neurovascular state of pulse, motor, and sensory, highlighting any distinctive flexion limits or pain exacerbations. I will do the Talar Tilt Test to examine a lateral ankle sprain, the external rotation test to measure medial ligament injury, Thompson\’s test to examine the heel cord, and the compression test to evaluate the distal tibiofibular joint. I would be using the Ottawa ankle rule as a reference for radiologic diagnoses based on physical examination, and seek an x-ray if the client complains of pain in the malleolar zone, as well as pinpoint discomfort either to the lateral or medial malleolus, or incapacity to maneuver (Yilmaz et al.,2021).
Miklovic, T. M., Donovan, L., Protzuk, O. A., Kang, M. S., & Feger, M. A. (2018). Acute lateral ankle sprain to chronic ankle instability: a pathway of dysfunction. The Physician and sportsmedicine, 46(1), 116-122.
Lemme, N. J., Li, N. Y., DeFroda, S. F., Kleiner, J., & Owens, B. D. (2018). Epidemiology of Achilles tendon ruptures in the United States: athletic and nonathletic injuries from 2012 to 2016. Orthopaedic journal of sports medicine, 6(11), 2325967118808238.
Afonso, J., Clemente, F. M., Nakamura, F. Y., Morouço, P., Sarmento, H., Inman, R. A., & Ramirez-Campillo, R. (2021). The effectiveness of post-exercise stretching in short-term and delayed recovery of strength, range of motion and delayed onset muscle soreness: A systematic review and meta-analysis of randomized controlled trials. Frontiers in physiology, 12, 553.
Calin, M. A., Badila, A., Hristea, A., Manea, D., Savastru, R., & Nica, A. S. (2019). Fractionated irradiation in photobiomodulation therapy of ankle sprain. American journal of physical medicine & rehabilitation, 98(8), 692-698.
Singh, K., Thukral, C. L., Gupta, K., & Singh, A. (2018). Comparison of high resolution ultrasonography with clinical findings in patients with ankle pain. Journal of ultrasonography, 18(75), 316.
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Your assessment of RN, the 46-year-old Caucasian woman who presented to the clinic, was informative. It covered all the essentials of a SOAP note and captured the essence of an episodic/focused note instead of a comprehensive review. Out of the five differential diagnoses itemized, I would agree with your primary diagnosis of an ankle sprain because 4 of the five symptoms needed to confirm a diagnosis of an ankle sprain are present. These are a popping sound/ sensation, limited range of movement, instability, and pain around the ankle area (Vuurberg et al., 2018). These symptoms indicate damage to the strong ligaments that support the ankle.
Similarly, utilizing the Ottawa Ankle Rules to establish the radiograph requirement, ankle pain attributed to acute injuries as appropriate. As Murwanashyaka et al. (2020) note, acute injuries account for 1 of every four musculoskeletal injuries and more than 1 in every 3lower extremity injuries, thus emphasizing its significance in medical care. Suffice it to say that studies like that of the writers mentioned above have demonstrated Ottawa Ankle Rules have a high sensitivity and modest specificity in detecting ankle fractures in the absence of x-rays. Thus, they reduce healthcare costs and unnecessary extended stays at the Emergency Department. The other differentials of ankle fracture, Achilles tendon injury navicular fracture, and post-exercise soreness have been accounted for why you refuted them.
Despite these points of agreement in your patient assessment, I felt that one should use a mnemonic like LOCATES to take the history of the presenting musculoskeletal pain. According to Page et al. ( 2019), using such mnemonics where L stands for location, o for onset, c for the character of the pain, A for accompanying symptoms, T for timing, E for exacerbating and relieving factors, and S for severity on a 0-10 pint rating scale is easier compared to the additional questions you listed. Mnemonics, whether using songs, pictures, acronyms like this, rhymes, or other strategies, are helpful as they assist the nurse in recalling complex medical knowledge that one must understand comprehensively. Only by doing so can these professionals provide sufficient care to their patients.
Murwanashyaka, E., Buteera, A. M., Byimana, J., Bukara, E., Nzayisenga, A., & Byiringiro, J. C. (2020). Applicability of Ottawa ankle rules in predicting the need for radiography in ankle and midfoot injuries in Rwanda. East African Orthopaedic Journal, 14(1), 4-7.
Page, C., Cordon, C., & Wong, J. (2019). Evaluating the effectiveness of a mnemonic to guide staff when providing patient education to autologous hematopoietic stem cell transplant patients. Canadian Oncology Nursing Journal, 29(2), 123.
Vuurberg, G., Hoorntje, A., Wink, L. M., Van Der Doelen, B. F., Van Den Bekerom, M. P., Dekker, R., … & Kerkhoffs, G. M. (2018). Diagnosis, treatment and prevention of ankle sprains: update of an evidence-based clinical guideline. British journal of sports medicine, 52(15), 956-956.