APA format 3 peer references needs to review case study and document on differential diagnosis as to agreeing or disagreeing  Due October 20.2018 at 5pm Episodic/Focused SOAP Note Template Patient Information: A.S., 46 F, Caucasain S. CC “ankle pain in both ankles; worse in right ankle, after hearing ‘pop’ while playing soccer.” HPI : A.S. is a 46 year old Caucasian female who presents with bilateral ankle pain which she describes as chronic for the last 3 months. She acutely injured her right ankle 3 days ago while playing soccer. The pain is described as aching with intermittent sharp characteristics. Associated symptoms include limited ROM. The pain is worse with weight bearing and OTC pain medications have included alternating doses of Tylenol and Motrin with moderate relief. Current Medications :             Motrin 200 mg by mouth every 4-6 hours as needed for pain Hydrochlorothiazide 12.5mg by mouth daily for 6 months for HTN Allergies: PCN- rash, no known food/environmental allergies PMHx : HTN; immunizations are up to date- last tetanus 12/2017; flu shot 10/2018 cholecystectomy 2015 Soc Hx : A.S. is employed as a Registered Nurse and remains active by playing soccer three times a week. She is married with two teenage daughters. She denies tobacco and alcohol use.   Fam Hx : Maternal grandmother deceased at age 56 from MI. Maternal father deceased at age 75 from complications of COPD. Paternal grandparents unknown. Father history is unknown. Mother is alive with type 2 diabetes that is well controlled with oral agents. Sibling age 43 alive and well. Children are alive and well with no medical hx. ROS :. GENERAL:  No weight loss, fever, chills, weakness or fatigue. HEENT:  Eyes:  No visual loss, blurred vision, double vision or yellow sclerae. Ears, Nose, Throat:  No hearing loss, sneezing, congestion, runny nose or sore throat. SKIN:  No rash or itching. CARDIOVASCULAR:  No chest pain, chest pressure or chest discomfort. No palpitations or edema, RESPIRATORY:  No shortness of breath, cough or sputum. GASTROINTESTINAL:  No anorexia, nausea, vomiting or diarrhea. No abdominal pain or blood. GENITOURINARY:  No burning on urination. NEUROLOGICAL:  No headache, dizziness, syncope, paralysis, ataxia, numbness or tingling in the extremities. No change in bowel or bladder control. MUSCULOSKELETAL: pain and swelling to right ankle, limited weight bearing and ROM in b/l ankles, worse in the right ankle. No muscle cramping.  No back pain. HEMATOLOGIC:  No anemia, bleeding or bruising. LYMPHATICS:  No enlarged nodes. No history of splenectomy. PSYCHIATRIC:  No history of depression or anxiety. ENDOCRINOLOGIC:  No reports of sweating, cold or heat intolerance. No polyuria or polydipsia. ALLERGIES:  No history of asthma, hives, eczema or rhinitis. O. GENERAL:  AAOx 3, limping gait, no distress. No fever.  Skin is warm, dry, and intact. Skin of the lower extremities is warm and pink in color. CARDIOVASCULAR: chest is ...

1. APA format 3 peer references needs to review case study and
document on differential diagnosis as to agreeing or disagreeing
Due October 20.2018 at 5pm
Episodic/Focused SOAP Note Template
Patient Information:
A.S., 46 F, Caucasain
S.
CC
“ankle pain in both ankles; worse in right ankle, after hearing
‘pop’ while playing soccer.”
HPI
: A.S. is a 46 year old Caucasian female who presents with
bilateral ankle pain which she describes as chronic for the last 3
months. She acutely injured her right ankle 3 days ago while
playing soccer. The pain is described as aching with
intermittent sharp characteristics. Associated symptoms include
limited ROM. The pain is worse with weight bearing and OTC
pain medications have included alternating doses of Tylenol and
Motrin with moderate relief.
Current Medications
:
Motrin 200 mg by mouth every 4-6 hours as needed for
pain
Hydrochlorothiazide 12.5mg by mouth daily for 6 months for

2. HTN
Allergies: PCN- rash, no known food/environmental allergies
PMHx
: HTN; immunizations are up to date- last tetanus 12/2017; flu
shot 10/2018 cholecystectomy 2015
Soc Hx
: A.S. is employed as a Registered Nurse and remains active by
playing soccer three times a week. She is married with two
teenage daughters. She denies tobacco and alcohol use.
Fam Hx
: Maternal grandmother deceased at age 56 from MI. Maternal
father deceased at age 75 from complications of COPD. Paternal
grandparents unknown. Father history is unknown. Mother is
alive with type 2 diabetes that is well controlled with oral
agents. Sibling age 43 alive and well. Children are alive and
well with no medical hx.
ROS
:.
GENERAL: No weight loss, fever, chills, weakness or fatigue.
HEENT: Eyes: No visual loss, blurred vision, double vision or
yellow sclerae. Ears, Nose, Throat: No hearing loss, sneezing,
congestion, runny nose or sore throat.
SKIN: No rash or itching.
CARDIOVASCULAR: No chest pain, chest pressure or chest
discomfort. No palpitations or edema,
RESPIRATORY: No shortness of breath, cough or sputum.

3. GASTROINTESTINAL: No anorexia, nausea, vomiting or
diarrhea. No abdominal pain or blood.
GENITOURINARY: No burning on urination.
NEUROLOGICAL: No headache, dizziness, syncope, paralysis,
ataxia, numbness or tingling in the extremities. No change in
bowel or bladder control.
MUSCULOSKELETAL: pain and swelling to right ankle,
limited weight bearing and ROM in b/l ankles, worse in the
right ankle. No muscle cramping. No back pain.
HEMATOLOGIC: No anemia, bleeding or bruising.
LYMPHATICS: No enlarged nodes. No history of splenectomy.
PSYCHIATRIC: No history of depression or anxiety.
ENDOCRINOLOGIC: No reports of sweating, cold or heat
intolerance. No polyuria or polydipsia.
ALLERGIES: No history of asthma, hives, eczema or rhinitis.
O.
GENERAL: AAOx 3, limping gait, no distress. No fever. Skin
is warm, dry, and intact. Skin of the lower extremities is warm
and pink in color.
CARDIOVASCULAR: chest is symmetric with symmetrical
expansion, PMI noted at fifth intercostal space at the
midclavicular line, normal S1 and S2, no m/r/g, no edema in
legs, dorsalis pedis 2/4 bilaterally, normal hair distribution in
legs and no pigmentation of b/l legs.

4. MUSCULOSKELETAL: limited ROM and weight bearing in b/l
ankles, worse in right ankle. No clubbing, cyanosis, or edema.
NEUROLOGICAL: mood and affect appropriate, CN II-XII
intact. Motor: 5/5 in upper and lower extremities, DTRs 2+
bilaterally.
Diagnostic results
:
Ankle x-ray- If the Ottawa ankle rule is positive (bone
tenderness at posterior malleolus, bone tenderness at posterior
medial malleolus, or inability to bear weigh > 4 steps) ankle
radiographs are indicated (Polzer, Kanz, Prall, Haasters,
Ockert, Mutschler, & Grote, 2012).
If ankle radiographs negative- assess ligament in affected
extremity as compared to un-injured extremity by doing the
crossed leg test, squeeze test, external rotation test, anterior
drawer test, and talar tilt test. These tests will assist in
determining the need for an MRI and also grading the sprain
(Polzer, Kanz, Prall, Haasters, Ockert, Mutschler, & Grote,
2012).
Labs may include a uric acid level which is elevated with gout
and a WBC which would be elevated with osteomyelitis. MRI
imaging may also be indicted.
A
.
Sprain- because the patient heard the "pop" sound, her injury is
likely related to an ankle sprain in which the ligaments and
tissue that surround the bones of the ankle are injured causing
swelling, pain, and limited ROM (PubMed Health, 2018).

5. Fracture- a fracture would be unlikely if the patient was able to
bear weight after the injury. The area would also become
ecchymotic with limited to no ROM (PubMed Health, 2018).
Osteomyelitis- the extremity would be warm, erythematous, not
usually associated with an acute injury, potential fever present,
usually associated with a systemic infection or a wound (Ball,
Dains, Flynn, Solomon, & Stewart, 2015)
Gout- associated with hot, swollen joints, pain and limited ROM
(Ball, Dains, Flynn, Solomon, & Stewart, 2015)
Bursitis- limited ROM, swelling, pain, warmth, and point
tenderness (Ball, Dains, Flynn, Solomon, & Stewart, 2015)
References
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.
Polzer, H., Kanz, K. G., Prall, W. C., Haasters, F., Ockert, B.,
Mutschler, W., & Grote, S. (2012).
Diagnosis and treatment of acute ankle injuries: development of
an evidence-based algorithm.
Orthopedic Reviews, 4
(1), e5. http://doi.org/10.4081/or.2012.e5
PubMed Health. (2018). Ankle sprains: overview. Retrieved
from
https://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0072736/