In this Discussion, you will consider case studies that describe abnormal findings in patients seen in a clinical setting.
Assigned to one of the following specific case studies for this Discussion. Also, your Discussion post should be in the SOAP Note format, rather than the traditional narrative style Discussion posting format.
Case 2: Ankle Pain
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? SEE ATTACHMENT FOR THE ANKLE X-RAY.
To prepare:
With regard to the case study you were assigned:
•Review this week’s Learning Resources, and consider the insights they provide about the case study.
•Consider what history would be necessary to collect from the patient in the case study you were assigned.
•Consider what physical exams and diagnostic tests would be appropriate to gather more information about the patient’s condition. How would the results be used to make a diagnosis?
•Identify at least five possible conditions that may be considered in a differential diagnosis for the patient.
Post on 1 TO 2 PAGES OF SOAP NOTE ON : A description of the health history you would need to collect from the patient in the case study to which you were assigned. Explain what physical exams and diagnostic tests would be appropriate and how the results would be used to make a diagnosis. List five different possible conditions for the patient’s differential diagnosis, and justify why you selected each. Include how the patient X-ray helped you to refine the differential diagnosis.
Reference
Readings
•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.
◦ Chapter 4, “Vital Signs and Pain Assessment” (pp. 50-63)
◦Chapter 21, “Musculoskeletal System” (pp. 501-543
Dains, J. E., Baumann, L. C., & Scheibel, P. (2016). Advanced health assessment and clinical diagnosis in primary care (5th ed.). St. Louis, MO: Elsevier Mosby
. ◦Chapter 22, “Limb Pain” (pp. 356-374)
Sullivan, D. D. (2012). Guide to clinical documentation (2nd ed.). Philadelphia, PA: F. A. Davis.
◦Chapter 2, “The Comprehensive History and Physical Exam” (“Muscle Strength Grading”; p. 26)
