Episodic/Focused SOAP Note Template

Review of Case Study #2

Patient Information:

Case Study #2: 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.

AB, Age 46, Female, Caucasian

CC: "My ankle hurts, and more specifically on the right side after I heard a pop while playing soccer”.

HPI: The patient is a 46-year-old Caucasian female who presents with bilateral ankle pain for 2 days that
was initiated while playing soccer and hearing a pop sound. Reports the pain is throbbing and sharp.
Reports ability to bear weight with more pain on the right ankle. Reports pain of 6/10 on bilateral ankles
and the right ankle pain increases to 8/10 with weight bearing exercises. Alleviating factors include ice
packs that assist with decreasing the swelling and ibuprofen for pain. Denies headache and fever.

Current Medications:

OTC Ibuprofen 200 mg every 6-8 hours PRN pain

OTC Tylenol 500 mg every 4-6 hours PRN for pain

Oral contraceptives once daily

Allergies: No drug allergies. No food allergies. No environmental allergies.

PMHx:

Medical: Patient reportedly sprained right ankle in 2021.

Surgical: Tonsillectomy and adenoidectomy - 1985

Immunizations: This patient is up-to-date with childhood vaccinations. Received current flu and COVID
vaccine. Last tetanus vaccine 2/23/2022. Patient has never received the pneumonia vaccine.

Soc Hx: The patient is paramedic and has been working in the field for 20 years. Reports being single and
living alone with 2 cats and 1 dog. Reports drinking 2-3 glasses of wine per week. Denies tobacco and
illicit drug use. Reports moderate exercise routine 3 days per week. Reports being active within the local
volunteer fire department. Reports a moderate amount of stress level. Reports a caffeine intake of 2
cups of coffee per day.

Fam Hx:

Mother – Hypotension; Pacemaker, osteoporosis

Father – Hypertension, Type 2 Diabetes Mellitus

Maternal Grandmother – Osteoporosis

Maternal Grandfather – deceased at age 75 due to motor vehicle accident

Paternal Grandmother – Hypertension, obesity, deceased at age 78 due to myocardial infarction

Paternal Grandfather – Hypertension, obesity, deceased at age 86 due to stroke

ROS:

GENERAL: Cooperative 46-year-old female. No acute distress. Denies weight loss, fever, chills or
weakness.

HEENT: Eyes: Denies visual loss. No use of contact lenses or glasses.

Ears, Nose, Throat: Denies hearing loss, sneezing, congestion, runny nose or sore throat. Last dental visit
was 4 months ago.
SKIN: Denies rash or itching.

CARDIOVASCULAR: Denies chest pain, chest pressure or chest discomfort. No palpitations or edema.

RESPIRATORY: Denies shortness of breath, cough or sputum.

GASTROINTESTINAL: Denies anorexia, nausea, vomiting or diarrhea. No abdominal pain or blood.

GENITOURINARY: Denies burning on urination. Last menstrual period, 9/16/2023.

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

MUSCULOSKELETAL: Bilateral ankle pain with greater pain on the right side.

HEMATOLOGIC: Denies anemia, bleeding or bruising.

LYMPHATICS: Denies enlarged nodes. No history of splenectomy.

PSYCHIATRIC: Denies history of depression or anxiety.

ENDOCRINOLOGIC: Denies reports of sweating, cold or heat intolerance. No polyuria or polydipsia.

ALLERGIES: Denies history of asthma, hives, eczema or rhinitis.

Physical exam:

Vital Signs: Temp 98.7 F, HR 74, BP 126/68, Resp 16, O2 99% on RA, Height 5’4”, Wt 160 lbs, BMI: 27.5
HEENT: Head normocephlic, no trauma. Pupils equal and reactive to light. Ears symmetrical, no
tenderness or discharge. No turbinate inflammation, no frontal or maxillary sinus tenderness. Nasal
mucosa pink and moist. Oropharynx without tonsillar enlargement, erythema, or exudates. Buccal
mucosa moisture without lesions. No dentures, good hygiene.

Neck: Supple with full ROM. No adenopathy. No thyromegaly, no masses.

CV: Heart RRR, no murmurs or gallops. No peripheral edema.

Respirations: Breath sounds clear all fields. Diaphragmatic excursion is symmetrical.

Abdomen: Soft, nondistended. No organomegaly or masses. Bowel sounds are present and normoactive
in all four quadrants.

Musculoskeletal: Right ankle edema +2 with tenderness on palpation of lateral side and ecchymosis 2
cm x 3 cm on lateral malleolus location. Limited range of motion with dorsiflexion, plantar flexion, and
inversion on bilateral ankles with pain. Pain noted on rotation of bilateral ankles with greater pain on
right than left. No deformity, crepitus, or bony tenderness.

Neurological: Alert and oriented x4, cranial nerves II-XII intact, no motor deficits. Gait weak on right
ankle.

Diagnostic results:

Labs – N/A

Imaging – X-Ray – internal rotation view of ankles

1. A.

Differential Diagnoses
Lateral Ankle Sprain: Typically, in a lateral ankle sprain, swelling and pain are noted on the anterior
talofibular ligament (ATFL) and calcaneofibular (CFL) ligaments with an absence of swelling and
ecchymosis on the toes or forefoot (Halabchi & Hassabi, 2020). The Ottawa Ankle Rules (OAR) involves
the use of a questionnaire and research algorithm utilized to assist with an ankle and foot examination
(Kerkhoffs, et. Al., 2012). Assessment of active, passive, and resistive range-of-motion (ROM) can assist
in the differentiation of injuries involving the ligaments, tendons, muscles, and nerves (Halabchi &
Hassabi, 2020). The patient’s presenting symptoms meet criteria to be applicable for this diagnosis.

Ankle Fracture: If a severe ankle sprain has occurred, ruling out an ankle fracture can be completed
using the OAR and the use of radiological imaging can be used in assistance of the diagnosis (Lampridis,
et. al., 2018). The use of the OAR technique will assist in ruling out the fracture for the patient and
presenting symptoms.

Achilles Tendinopathy: Upon diagnosing achilles tendinopathy, radiographic imaging is obtained on a

routine basis if the patient is experiencing symptoms that last longer than six week that will aid in ruling
out bony abnormalities and in identifying the potential for ossification and intratendinous calcific
deposits (Maffulli, et. al., 2020). The most common presenting symptom of achilles tendinopathy is heel
pain that is predominantly seen amongst athletes that is related to an excessive load greater than the
tendon’s capacity (Tabane, 2022).

Ankle Impingement Syndromes: Ankle Impingement Syndrome typically affects the young and athletic
population with complaints including chronic ankle pain, limited dorsiflexion, and edema after
ambulation or activity (Diniz, et. al., 2020). The most characteristic symptom of Ankle Impingement
Syndrome is a diagnostic technique that is positive for pain when direct pressure is applied over the
anterolateral ankle while the foot is in the dorsiflexion position (Diniz, et. al., 2020).

P.

This section is not required for the assignments in this course (NURS 6512) but will be required for
future courses.

References
Diniz, P., Sousa, D. A., Batista, J. P., Abdelatif, N., & Pereira, H. (2020). Diagnosis and

treatment of anterior ankle impingement: state of the art. Journal of ISAKOS, 5(5), 295

-303.

Halabchi, F., & Hassabi, M. (2020). Acute ankle sprain in athletes: Clinical aspects and

algorithmic approach. World journal of orthopedics, 11(12), 534.

Ishibashi, M. A., Doyle, M. D., & Krcal, C. E. (2023). Posterior Ankle Impingement

Syndrome. Clinics in Podiatric Medicine and Surgery, 40(1), 209-222.

Kerkhoffs, G. M., van den Bekerom, M., Elders, L. A., van Beek, P. A., Hullegie, W. A.,

Bloemers, G. M., ... & de Bie, R. A. (2012). Diagnosis, treatment and prevention of

ankle sprains: an evidence-based clinical guideline. British journal of sports

medicine, 46(12), 854-860.

Lampridis, V., Gougoulias, N., & Sakellariou, A. (2018). Stability in ankle fractures: diagnosis

and treatment. EFORT open reviews, 3(5), 294-303.

Maffulli, N., Longo, U. G., Kadakia, A., & Spiezia, F. (2020). Achilles tendinopathy. Foot and

Ankle Surgery, 26(3), 240-249.

Tabane, C. (2022). Achilles tendinopathy. South African General Practitioner, 3(1), 22-25.

Vuurberg, G., Hoorntje, A., Wink, L. M., Van Der Doelen, B. F., Van Den Bekerom, M. P.,

Dekker, R., ... & Kerkhoffs, G. M. (2018). Diagnosis, treatment and prevention of ankle

sprains: update of an evidence-based clinical guideline. British journal of sports

medicine, 52(15), 956-956.