Use the Episodic/Focused SOAP Template and create an episodic/focused note about the patient in the case study 1 & 2 to which you were assigned using the episodic/focused note template provided in the Week 5 resources. Provide evidence from the literature to support diagnostic tests that would be appropriate for each case. List five different possible conditions for the patient’s differential diagnosis and justify why you selected each.
Below is the case study 1 to be used Case Study 1 : Acute Ankle Injury in a 46-Year-Old Female Soccer Player
A 46-year-old female soccer player presented to the clinic with complaints of severe pain in both ankles, with the right ankle being more concerning. The patient reported that the symptoms began over the weekend during a soccer game when she suddenly heard a ‘pop’ sound. She described the pain as intense, rating it as eight out of 10 on a pain scale. The pain worsened with movement and was slightly relieved by taking Ibuprofen. Although she could bear weight on both limbs, she experienced discomfort while doing so.
Upon further inquiry, the patient denied any history of similar injuries in the past. She reported no previous hospitalizations or surgeries, and her medical history was unremarkable, with no history of chronic conditions such as hypertension, diabetes, or asthma. The patient was not currently on any medications other than Ibuprofen for pain relief, and she had no known allergies to food, drugs, or environmental factors.
During the physical examination, the patient appeared well-nourished and in no acute distress. Her vital signs were within normal limits. In the musculoskeletal examination, the patient exhibited pain in both ankles, with the right ankle being more affected. There were no visible signs of joint swelling or deformities, and she had no limitations in other joints. Case Study 2: Bilateral Knee Pain in a 15-Year-Old Male Baseball Player
Jake Smith, a 15-year-old Caucasian male, presented to the clinic with complaints of bilateral knee pain accompanied by a clicking and catching sensation. He reported that the pain began approximately two weeks ago and described it as a dull ache located in the posterior aspect of both knees. Additionally, he felt pressure behind both knees. Jake attributed the onset of pain to his participation in baseball practice. Activities such as exercise, running in gym class, and sports exacerbated the pain, while rest and ibuprofen provided relief. He rated his pain as 4 out of 10 during the current visit, but noted that it typically increased to 7 out of 10 after baseball practice and gym class.
Jake’s medical history was unremarkable, with no previous surgeries or significant childhood diseases reported. He regularly took Olly Kids Multivitamin + Probiotic as a supplement for immune support and consumed Ibuprofen as needed for pain relief. There were no known allergies to medications, food, latex, or environmental factors.
In terms of social history, Jake lived with his parents, younger brother, and younger sister. He attended Cardinal High School and enjoyed playing baseball in the spring, with plans to participate in football during the fall season. His mother worked as a second-grade schoolteacher, while his father worked as an engineer at a local factory. Jake had access to healthcare providers and maintained a healthy diet. He denied tobacco, alcohol, and illicit drug use, although he mentioned that some of his friends had recently started vaping. Jake denied engaging in sexual activity.
The family history revealed his maternal grandmother had a history of hypertension and breast cancer, resulting in a bilateral mastectomy in 2018. His maternal grandfather had hypertension and high cholesterol levels. On his paternal side, his grandmother had type 2 diabetes, hypertension, and high cholesterol levels. There were no significant medical conditions reported for his paternal grandfather. Jake’s younger brother had asthma, while his younger sister had no significant medical history.
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Introduction:
In this assignment, I will be using the Episodic/Focused SOAP template to create an episodic/focused note for two different case studies. The first case study involves a 46-year-old female soccer player with an acute ankle injury, while the second case study involves a 15-year-old male baseball player with bilateral knee pain. I will also provide evidence from the literature to support diagnostic tests that would be appropriate for each case. Additionally, I will list five different possible conditions for each patient’s differential diagnosis and justify the selection of each condition.
Answer:
Case Study 1: Acute Ankle Injury in a 46-Year-Old Female Soccer Player
Subjective:
– A 46-year-old female soccer player presents with severe pain in both ankles, with the right ankle being more concerning.
– The onset of symptoms occurred during a soccer game over the weekend when the patient heard a ‘pop’ sound.
– The patient rates the pain as eight out of 10 on the pain scale and reports that it worsens with movement.
– Ibuprofen slightly relieves the pain.
– The patient denies any previous similar injuries, hospitalizations, surgeries, or history of chronic conditions.
– Current medication includes only Ibuprofen, and there are no known allergies.
Objective:
– The patient appears well-nourished and is not in acute distress.
– Vital signs are within normal limits.
– Pain is primarily located in the right ankle, and there are no visible signs of joint swelling or deformities.
– No limitations are observed in other joints.
Assessment:
1. Ankle Sprain: The patient’s history of hearing a ‘pop’ sound during a soccer game, severe pain, and ability to bear weight with discomfort suggest a potential ankle sprain.
2. Ligament Tear: A ligament tear can be considered due to the sudden onset of pain during activity, severity of pain, and absence of joint swelling or deformities.
3. Fracture: Although there are no visible signs of deformity, the possibility of a fracture cannot be ruled out completely as fractures may not always present with obvious signs.
4. Tendon Injury: The patient’s symptoms, such as the ‘pop’ sound and ongoing pain, may indicate a possible tendon injury.
5. Overuse Injury: Given the patient’s history as a soccer player and the absence of other chronic conditions or previous injuries, an overuse injury may be considered as a possible condition.
Diagnostic Tests:
1. X-ray: To rule out fractures or detect potential bony abnormalities.
2. MRI: Useful for evaluating soft tissue injuries, such as ligament tears or tendon injuries.
3. Ultrasound: Can provide detailed imaging of tendons and ligaments.
4. Physical Examination: An assessment of joint stability and range of motion can aid in diagnosing ligament injuries or instability.
5. Ankle Arthroscopy: In cases where other diagnostic tests are inconclusive, arthroscopy may be performed to directly visualize and diagnose internal joint injuries.
Overall, the patient’s history, symptoms, and physical examination findings suggest potential conditions such as an ankle sprain, ligament tear, fracture, tendon injury, or overuse injury. Diagnostic tests, such as X-ray, MRI, ultrasound, and physical examination, can aid in confirming or ruling out these conditions.
