Case Study For Advanced Health Assessment Paper

Case Study For Advanced Health Assessment Paper

By Day 1 of this week, you will be assigned to one of the following specific case studies for this Discussion. Please see the â€œCourse Announcementsâ€ section of the classroom for your assignment from your Instructor.
Your Discussion post should be in the Episodic/Focused SOAP Note format rather than the traditional narrative style Discussion posting format. Refer to Chapter 2 of the Sullivan text and the Episodic/Focused SOAP Template in the Week 5 Learning Resources for guidance. Remember that all Episodic/Focused SOAP notes have specific data included in every patient case. Case Study For Advanced Health Assessment Paper

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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 Ottawa ankle rules to determine if you need additional testing? Case Study For Advanced Health Assessment Paper

Ankle Focused SOAP Note

Patient Initials: _RP____ Age: ____46___ Gender: ___F____

CC (chief complaint): Ankle pain

HPI: Regina Pinkett is a 46-year-old Hispanic female patient who presented to our hospital with complaints of pain and swelling in both of her ankles. She reported that the pain and the swelling have been there for the past 4 days after a landing in which she heard a popping sound from her ankle during her soccer game over the weekend. She also reported that the pain is more acute in her right ankle. The pain has worsened despite using rest, ice, compression, and elevation (RICE) treatment. She rated the severity of her pain as 7/10. Case Study For Advanced Health Assessment Paper

Current Medications: No medication used

Allergies: No known history of allergy to the environment, food, or drugs

PMHx:

1.) Type 2 diabetes mellitus

Immunization History:

COVID-19 Vaccine #1 5/17/2021 #2 6/13/2021 Moderna Vaccine – Spikevax

Booster shot 7/9/2021 Moderna Vaccine – Spikevax

Received all basic childhood immunization

Soc & Substance Hx: Denied ETOH or illicit drug use; denied smoking

Regina Pinkett is the only child of her Hispanic parents and lived with both parents in the city during her schooling. She works as an elementary school teacher in an elementary school that is a walking distance. She lives with her two adopted children in her home in the city. Her residence area is a cool environment with good public transportation although she owns a car. She is financially stable and finds great life satisfaction and support from her parents and her adopted son and daughter. She has Medicaid insurance, eats healthy, and generally lives a healthy lifestyle. She likes taking walks in the evening and playing soccer sometimes. Case Study For Advanced Health Assessment Paper

Fam Hx: Mother – Type 2 diabetes; Father—Hypertension

Surgical Hx: No history of major surgery

Mental Hx: Denied history of anxiety or depression

Violence Hx: Denied history of violence

Reproductive Hx: Gravida 0 Para 0; heterosexual; no sexual partner; not on any family planning method; no biological children

ROS:

GENERAL: No recent weight loss or gain of significance; pain and swelling in both ankles; discomfort on movement; no fever, chills, night sweats

HEENT: Eyes: Negative for visual loss, blurred vision, double vision, or yellow sclerae. Ears, Nose, Throat: No hearing loss, sneezing, congestion, runny nose, or sore throat.

NECK: No pain, injury, or history of disc disease or compression

SKIN: Negative for rash, itching, or discoloration

CARDIOVASCULAR: Negative for chest discomfort, pressure, or pain; no palpitations or edema; negative for paroxysmal nocturnal dyspnea, orthopnea, or arrhythmias

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RESPIRATORY: Negative for shortness of breath, cough, or sputum.

GASTROINTESTINAL: No abdominal pain; No nausea, vomiting, diarrhea, or anorexia

NEUROLOGICAL: Negative for headache, dizziness, ataxia, paralysis, syncope, tingling, or numbness in the extremities. No change in bowel or bladder control.

MUSCULOSKELETAL: Pain in the ankle with no other joint pain; negative for stiffness, back pain, muscle pain, or stiffness; swelling; negative for skin coloring, rashes, or heat around the ankle

HEMATOLOGIC: Negative for anemia, bleeding, or bruising. No history of clotting difficulties or transfusions

LYMPHATICS: Negative for enlarged nodes. No history of splenectomy.

PSYCHIATRIC: Denied history of anxiety or depression. Negative for sleep disturbance, delusions, or mental health history. No homicidal or suicidal history

ENDOCRINOLOGIC: Negative for sweating, cold, or heat intolerance. No polyuria or polydipsia

GENITOURINARY/REPRODUCTIVE: Normal urinary frequency; negative for dysuria, or incontinence. Normal urination urgency, hesitancy, odor, and color.

LMP: 7/14/2022; negative for breast lumps, pain, or discharge; negative for vaginal pain or discharge

ALLERGIES: No known history of allergy to the environment, food, or drugs Case Study For Advanced Health Assessment Paper

Physical exam:

Vital signs: T 98.6 °F orally; B/P 134/80 mm Hg, P 92 and regular; RR 14 non-labored; Wt: 132 lbs; Ht: 5’5; BMI 22

General: A&O x4, NAD, appears comfortable

HEENT: PERRLA, EOMI, oronasopharynx is clear

Neck: Carotids no bruit, jvd or thyromegaly

Chest/Lungs: Negative for wheezing, negative for scattered rhonchi

Heart/Peripheral Vascular: RRR without murmur, rub or gallop; pulses +2 bilat pedal and +2 radial

ABD: Nabs x 4, no organomegaly; no suprapubic pain or tenderness

Musculoskeletal: Symmetric muscle development; 5/5 muscle strength in all groups.

Neuro: CN II – XII grossly intact, DTR intact

Diagnostic results:

Lab tests:

Complete Blood Count (CBC) – Within normal levels

C-reactive protein (CRP) – Within normal levels

Erythrocyte Sedimentation Rate – Within normal levels

Rheumatoid Factor – Negative

Uric acid blood test – Within normal levels Case Study For Advanced Health Assessment Paper

Radiography

Ankle X-Ray

MRI

Primary Diagnosis:

Ankle sprain

Differential Diagnoses:

Ankle sprain
Achilles tendinitis
Fracture
Rheumatoid arthritis
Gout

Documentation of clinical data helps in making a differential diagnosis and the primary diagnosis (Sullivan, 2019). Symptoms presented by the patient such as pain and swelling in both ankles for four days, pop sound from the ankle, and discomfort with movement are associated with an ankle sprain, Achilles tendinitis, fracture, rheumatoid arthritis, and gout (Ball et al., 2019). Achilles tendinitis is characterized by pain, swelling, tenderness, and stiffness on the heel. However, the patient experienced pain localized to the inside of the ankle therefore Achilles tendinitis is ruled out (Dains et al., 2018). Rheumatoid arthritis and gout are characterized by pain and stiffness of the ankle, especially in the morning, fever, elevated WBCs, ESR, and CRP (Dains et al., 2018). Lab results for the patient indicate normal values. Further, negative results for RF indicate the absence of rheumatoid arthritis (Mostofi et al., 2022). Also, negative results for the uric acid blood test confirm the absence of gout (Dains et al., 2018). Fracture and ankle sprain are characterized by pain and swelling in the ankle, pop or cracking sound associated with the cause of the injury, and absence of fever (Ball et al., 2019)Case Study For Advanced Health Assessment Paper . By applying the Ottawa ankle rules, ankle X-Ray and MRI were performed and the results indicated no fracture (Li et al., 2017). Following analysis of the subjective and objective data, physical examination, radiography, and lab test results, ankle sprain was considered the primary diagnosis.

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[This section is not required for the assignments in this course, but will be required for future courses.]

References

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Seidel’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby.

Dains, J. E., Baumann, L. C., & Scheibel, P. (2018). Advanced Health Assessment & Clinical Diagnosis in Primary Care (5th ed.). Elsevier Health Sciences.

Li, N., Liu, Y. S., Xin, J. Y., Ma, X. L., Mei, X. L., Shi, Z. K., Li, G., & Sun, Z. H. (2017). Efficiency of the Modified Ottawa ankle rules for the differential diagnosis of fracture in acute foot and ankle injury. Europe PMC, 7(35), 2742-2745. https://doi.org/10.3760/cma.j.issn.0376-2491.2017.35.006

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

Mostofi, S.B., Fazli, A., Sussman, W.I. (2022). Anterior Ankle Disorders. In: Mostoufi, S.A., George, T.K., Tria Jr., A.J. (eds) Clinical Guide to Musculoskeletal Medicine. Springer, Cham. https://doi.org/10.1007/978-3-030-92042-5_47 Case Study For Advanced Health Assessment Paper