Focused SOAP Note Assessing Musculoskeletal Pain Discussion

Focused SOAP Note Assessing Musculoskeletal Pain Discussion

Assessing Musculoskeletal Pain

The patient presents with right ankle pain. According to Morais et al. (2021), ankle injuries are the most common cause of visits to the emergency department. Additionally, it is crucial to determine the cause of pain by identifying the structures involved and other symptoms the patient may exhibit. Also, it will pinpoint differential diagnoses, the physical examinations to complete, special maneuvers, and lastly, describe whether or not to use the Ottawa ankle rule.

Episodic/Focused SOAP Note Assessing Musculoskeletal Pain

The structures involved in the lateral ankle are anterior inferior tibiofibular ligament, anterior and posterior talofibular ligament, calcaneofibular ligament, lateral malleolus, peroneus longus, peroneus brevis muscle and tendon, talus, cuboid bone, navicular bone (Wagner, n.d.).

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Patient Information:

AW, age 46, female, Caucasian

S.

CC: Pain in both ankles, mainly right ankle

HPI: 46-year-old Caucasian female presents with bilateral ankle pain. The patient is more concerned about the right ankle as she heard a “pop” while playing soccer over the weekend. Focused SOAP Note Assessing Musculoskeletal The pain is sharp when bearing weight on the right foot, and the pain is throbbing and dull when resting. The patient is weight-bearing on the right foot, but it is uncomfortable. She rates pain one out of ten on the pain scale for the left ankle and eight out of ten on the pain scale for the right foot. The patient denies pain radiating; she reports minor swelling and bruising on the right ankle and denies any bruising or swelling on the left ankle. The patient applied an ice pack to the right ankle on and off and alternated Tylenol and ibuprofen for pain and swelling. The patient denies weight loss, fever, and numbness.

Current Medications:

Multivitamin one tablet daily for 40 years

Tylenol 650 milligrams every four to six hours as needed for pain and swelling; last dose ten pm Ibuprofen 800 milligrams every six to eight hours as needed for pain and swelling at eight this morning

The patient denies homeopathic use

Allergies: Penicillin – Hives and rash; denies latex, food, or environmental allergies

PMHx: Flu vaccine 2021, Tetanus booster 2018, all childhood immunizations are up to date, previous right ankle sprain 2019, denies surgical history, hospitalization for a vaginal birth without complications. The patient denies any significant illnesses.

Soc Hx: The patient is single with one child, age 16. She coaches soccer at a local community college. The patient denies smoking, drinking, and utilizing recreational drugs. She exercises daily by biking, riding, running, playing soccer, and walking; she eats a well-balanced diet of fruits, vegetables, and meats such as fish, chicken, and beef. She drinks one caffeinated beverage daily and 64 ounces of water daily. She wears her seatbelt while in the car and has a great support system with friends and family. The patient denies current sexual activity and has a prior history of sexually transmitted diseases.

Fam Hx: Paternal grandfather died at 89 due to myocardial infarction, Paternal grandmother died at 78, had osteoarthritis, obese, Maternal grandfather is 90 living with dementia, Maternal grandmother died at 70, diabetes, osteoporosis, Father is 70 living with arthritis, hypertension, high blood pressure, Mother is 66 with diabetes, Sister is 42 living and well denies any medical history, Daughter is 16 living and well no current medical history.

ROS

GENERAL: No weight loss, fever, chills, weakness, or fatigue, decreased activity
RESPIRATORY: Denies shortness of breath, cough, sputum production
CARDIOVASCULAR: No chest pain, chest pressure, or chest discomfort. No palpitations or edema, no syncope
NEUROLOGICAL: No headache, dizziness, syncope, paralysis, ataxia, numbness, or tingling in the extremities. No change in bowel or bladder control.
HEMATOLOGIC: No anemia, bleeding, or bruising.
LYMPHATIC: No swollen lymph glands
MUSCULOSKELETAL: No muscle, back pain, stiffness, pain, and swelling lateral aspect of right ankle
SKIN: No rash or itching, bruising
PSYCHIATRIC: No history of depression or anxiety
O.

Physical exam

Vital Signs: O2: 98%, Temperature: 98.6, Pulse: 70, Respirations: 18, Blood pressure: 130/72, Height: 172.72 centimeters and weight 65.77 kilograms
General: Alert and oriented x4, cooperative with exam, mild distress
Respiratory: Lungs clear bilaterally, no wheezes or rhonchi, symmetrical expansion
Cardiovascular: Regular rate and rhythm, S1 and S2, no murmur, gallop, good pulses in all extremities 2+
Lymphatic: No lymphadenopathy groin
Hematologic: Bruising
Musculoskeletal: Smooth and round malleolar prominences, prominent heels, prominent metatarsophalangeal joints, no corn or calluses, weight-bearing midline of the foot, the longitudinal arch, ecchymosis noted lateral foot, and swelling, tenderness of right ankle, no heat or redness noted bilaterally, limited range of motion in the right ankle, no instability of hips or knees. A drawers test, external rotation test, eversion stress test, and physical exam and history can help determine a diagnosis (Larkins et al., 2020).
Skin: Warm, pink, dry, intact, no rash
Neurological: Alert and oriented, sensation in upper and lower extremities equal, no numbness, no ataxia, motor symmetrical and intact
Psychiatric: Cooperative, mood and affect appropriate, judgment appropriate
Diagnostic results: As a patient may experience ankle injuries in their life, it is crucial to provide the utmost care to the patient. According to Ball et al. (2019), the Ottawa Ankle Rules (OAR) will assist in identifying patients that display characteristics needing an x-ray. The OAR involves pain in the malleolar and one of the following, unable to bear weight for four steps following the injury, bone tenderness along the distal six centimeters of the posterior edge of the fibula or tibia of the lateral malleolus, or bone tenderness along the distal six centimeters of the posterior edge of the tibia or tip of the medial malleolus (Ball et al., 2019).

X-ray is the most common radiographic tool utilized to assess orthopedic issues. The darker view is a break in the bone or less dense, soft tissue, and the white or light appearance is tumors, calcium deposits, bones, or other dense matter (American Academy of Orthopedic Surgeons, 2021).

Computed Tomography can see more details of the body and tissues. American Academy of Orthopedic Surgeons (2021) provides a more detailed image allowing the provider to look at the position of structures, size, and shape deep within tissues or body.

Magnetic Resonance Imaging (MRI) is a tool that provides high-resolution images of soft tissues and bones and identifies torn ligaments (American Academy of Orthopedic Surgeons, 2021).

A.

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Differential Diagnoses

Ankle sprain is an injury to one or several ligaments in the ankle, typically on the outside, with abnormal gait, stiffness, deformity, instability, pain that can be sharp or dull, and swelling seen in sport-related injuries (Alazzawi et al., 2017).
Peroneal tendon syndrome is lateral hindfoot discomfort and instability involving the exact location of an ankle injury, making it more challenging to diagnose the source of pain (Sharma et al., 2020).
Anterior ankle impingement is a syndrome that results in severe restriction of ankle movements due to tendinous, loose ligaments, and bony abnormalities in the ankle joint; the soft tissue or osseous growth is due to mechanical entrapment (Al-Riyami et al., 2017). A complete and thorough history and physical examination can help determine a diagnosis. Assessing Musculoskeletal Pain Common symptoms are ankle pain, focal tenderness, ankle joint, and soft tissue swelling, commonly seen in soccer players (Al-Riyami et al., 2017).

Calcaneus secundarius is the well-corticated bony structure on the anterior facet of the calcaneus, which is a cause of ankle pain that is chronic and can be mistaken for a fracture; the patient may present with foot pain, swelling, no ecchymosis (Sabrina et al., 2021).
Ankle fracture is a complete or partial break in the bone. The patients may experience pain, inability to bear weight, swelling, and limited movement; they may feel a snap or pop; it does occur in patients with bone disorders, a deformity, color change, loss of function, and edema (Ball et al., 2019).

References

Focused SOAP Note Assessing Musculoskeletal Pain Discussion

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