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Nurs-6512 Case Week 8, A 46-year-old female reports pain in both of her ankles, but she is more
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Nurs-6512 Case Week 8, A 46-year-old female reports pain in both of her ankles, but she is more
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NURS 6512: Advanced Health Assessment and Diagnostic ReasoningWeek Eight: Assessment of the Musculoskeletal System
Review of case study #2: Ankle Pain
Scenario: A 46-year-old female reports pain in both of her ankles, but she is more concerned
about her right ankle. She was playing soccer over the weekend and heard a "pop." She is able to
bear weight, but it is uncomfortable. In determining the cause of the ankle pain, based on your
knowledge of anatomy, what foot structures are likely involved? What other symptoms need to
be explored? What are your differential diagnoses for ankle pain? What physical examination
will you perform? What special maneuvers will you perform? Should you apply the Ottowa
ankle rules to determine if you need additional testing?
Episodic/Focused SOAP Note for Throat Exam
Patient Information: G.M. Age: 46 y.o. Sex: Female DOB: 7/5/1971
S.
Chief Complaint/Reason for Visit:
“Both of my ankles hurt, but more severe on the right”
History of Present Illness:
Ms. G.M. is a 46-year-old Asian female that works as a physical education teacher at a
local school district who presented with reports of bilateral ankle pain for the past 2 days. Patient
reported that she was playing soccer over the weekend when she heard a “pop” sound during the
game. The pain initially ranges from 4/10 on both ankles but after 5-10 minutes her right ankle
pain started to increase. According to her, she was able to bear weight on both ankles but felt
more discomfort on the right side when walking or standing. Although applying cold compress
on both areas provides relief, she noticed that her right ankle seems swollen since yesterday.
This study source was downloaded by 100000839832718 from CourseHero.com on 04-25-2022 18:06:11 GMT -05:00
https://www.coursehero.com/file/28745589/NURS6512wk8d1docx/
, Patient does not recall any recent accident and stated that she has been actively playing different
sports such as soccer, tennis, and volleyball all her life. The only difference that she notices
during the game is she did not have enough time to warm-up since she was running late for the
game. Upon presentation, patient reported 5/10 on her right ankle and 2/10 on her left side.
Current Medications:
One-A-Day Women’s Multivitamins one tablet daily
Ferrous Sulfate 325mg once daily
Allergies: Nuts-hives
Immunization History:
Flu Vaccine: October 2017
PMHx:
• Anemia (2015, managed by Ferrous Sulfate)
Fam Hx: Reported both parents are healthy and alive. Father has hypertension.
Personal/Social History: Patient is single. Works as a physical education teacher full-
time. Does not smoke, drink or use any illicit drugs. Physically active, exercises 5-6 time
a week.
Review of Systems:
Constitutional: A&O x4, pleasant and cooperative. No acute distress. Denies weight loss,
weakness, or fatigue.
HEENT: Denies headache, sore throat or changes in vision and hearing.
SKIN: No rash or itching.
CARDIOVASCULAR: Denies chest pain or palpitations.
RESPIRATORY: Denies shortness of breath or cough.
This study source was downloaded by 100000839832718 from CourseHero.com on 04-25-2022 18:06:11 GMT -05:00
https://www.coursehero.com/file/28745589/NURS6512wk8d1docx/
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