Please provide a positive feedback to each discussion with references ( olubuk

Please provide a positive feedback to each discussion with references ( olubukola). Episodic/Focused SOAP Note
Patient Information:
Name: M.O Age: 46-year-old Sex: Female Race: Caucasian
S.
CC: “Ankle pain.”
HPI: MO is a 46-year-old Caucasian female who presents to the clinic with bilateral ankle pain for the past three days. She reported swelling in her right ankle. The ankle pain began after she played soccer over the weekend and noticed a “pop” sound. She describes it as a throbbing and achy pain. She can bear weight but reported worse discomfort on the right side. She experiences pain of a 5/10 on a pain scale in both ankles but rises to a 7/10 on the right side when walking or standing. OTC ibuprofen 400mg prn, elevation of legs, compression bandages, and applying ice packs provided short-term pain relief. Her pain is 5/10 on her right ankle and 3/10 on the left side.
Location: Bilateral ankle.
Onset: 3 days ago
Character: throbbing and achy pain.
Associated signs and symptoms: Swelling, inflammation, and tenderness. Timing: After playing soccer over the weekend.
Exacerbating/ relieving factors: Ibuprofen, elevation, compression, and application of ice provided temporary relief. Walking and standing made the pain worse.
Severity: 5/10 on a pain scale.
Current Medications: OTC Ibuprofen 400mg PO PRN for pain, oral contraceptive, Multivitamin P.O. daily Allergies: NKDA, no food, drug, or environmental allergies
PMHx: Right ankle sprain in 2017. She receives a flu vaccine annually. She was vaccinated for COVID-19 on 02/2021 and 03/2021. She received all childhood immunizations appropriately and was last vaccinated with a tetanus booster in 2017. She had a C-section once in 2005.
Soc Hx: She is married and has one male child, age 15. She is a chef at a local restaurant and does part-time football training at a nearby high school. She was athletic as a child and played football at international level. She exercises regularly during football training and runs every morning. She eats a healthy diet and enjoys a cup of coffee daily. She denied the use of alcohol, smoking, and use of illicit substances.
Fam Hx: Her mother is 75 and has a history of osteoarthritis, HTN, and breast cancer. Father is 80, with no significant health issues. He does not use alcohol or illicit drugs. She has two brothers, 40 and 38, with no vital health issues. Her son, age 15, is healthy. The health history of deceased grandparents includes arthritis, HTN, cirrhosis r/t alcoholism, HLD, and breast cancer.
ROS:
GENERAL: She denies weight loss, fever, chills, weakness, or fatigue.
HEENT: Eyes: Denies visual loss, blurred vision, double vision, or yellow sclerae. Ears, Nose, Throat: Denies hearing loss, sneezing, congestion, runny nose, or sore throat.
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: She denies anorexia, nausea, vomiting, or diarrhea: no abdominal pain or blood.
GENITOURINARY: She denies burning on urination, urgency, and polyuria. She is not pregnant; her last menstrual period was a week ago (07/11/2023).
NEUROLOGICAL: Denies headache, dizziness, syncope, paralysis, ataxia, numbness, or tingling in the extremities—no change in bowel or bladder control.
MUSCULOSKELETAL: Right ankle edema with 2x2cm ecchymosis on mid-lateral malleolus area with tenderness with palpitation on the lateral side. Range of motion with pain in bilateral ankles and limitation with dorsiflexion, plantar flexion, and inversion. Positive pain on rotation of ankles bilaterally with worsened pain on the right. No bony tenderness, deformity, or crepitus. Denies muscle stiffness.
HEMATOLOGIC: Denies anemia, bleeding, or bruising.
LYMPHATICS: Denies enlarged nodes—no history of splenectomy.
PSYCHIATRIC: Denies a history of depression or anxiety, confusion, or suicidal ideas.
ENDOCRINOLOGIC: Denies reports of sweating, cold, or heat intolerance: no polyuria or polydipsia.
ALLERGIES: Denies history of asthma, hives, eczema, or rhinitis.
O.
Physical exam:
Vital signs: BP 110/64; pulse 71; R.R. 17; SpO2 99%; Temp 98.7 oral; Wt: 136lbs; Ht: 5’4″. BMI: 20
General: She is alert & oriented to time, place, and situation. She appears uncomfortable and expresses pain.
HEENT: Head is normocephalic and atraumatic. PERRLA, EOMI is intact. Sclera is anicteric.
Skin: Warm and dry. No rashes, lesions, or excess bruising. Bruising to right lateral ankle noted.
Neck: Supple with unlimited range of motion.
Chest: Lungs clear to auscultation with chest expansion equal bilaterally. No cough or dyspnea.
Heart/P.V.: Regular rate and rhythm. S1, S2 noted without murmurs, rubs, or gallops. No edema except for the right lateral ankle. Bilateral posterior tibial pulses. No thrill 2+. Bilateral dorsalis pedis pulses no thrill 2+. Capillary refill in hands and feet in less than 3 seconds.
Musculoskeletal: Right lateral ankle is swollen, with limited ROM, weakness, and tenderness with palpation to the lower aspect of the fibula and surrounding ligaments (anterior and posterior tibiofibular ligaments, posterior and anterior talofibular ligaments, and calcaneofibular ligament) as well as lateral malleolus. There is generalized bruising to the lateral aspect of the right ankle. The medial part of the right ankle is non-tender, without bony deformities or bruising. Left ankle without swelling, bruising, or overt tenderness with palpation. No noted deformities or decreased range of motion to joints of toes, knees, hands, or fingers. The spine is straight. The patient can bear weight on the right foot, with pain. ROM limitation with dorsiflexion, plantar flexion, and inversion.
Neurological: Strength and sensation 5/5 in the upper and lower extremities bilaterally. Strength 3/5 in the right ankle.
Diagnostic Results:
The pain the patient is experiencing is located near the malleoli on the right side of the foot, and she also experiences tenderness. Therefore, the Ottawa ankle rule is needed to rule out ankle or malleolar fractures and determine if the patient requires radiographic imaging, for example, an X-ray or MRI. The Ottawa rule states that a patient with tenderness at the posterior edge or tip of the medial or lateral malleolus; inability to bear weight taking four steps either immediately after the injury or in the emergency room; or pain at the base of the fifth metatarsal can help detect nearly 100% fractures while significantly reducing the number of unnecessary radiographs (Chen et al.,2019). X-ray, MRI, and lower extremity ultrasonography are crucial to assess fractures, sprains, and ankle dislocation. An X-ray will rule out acute fractures.
A.
Differential Diagnoses
Lateral Ankle Sprain: Ankle sprains are common injuries affecting athletic and physically active populations. Most sprains affect the lateral ligaments, particularly the anterior talofibular ligament (Chen et al.,2019). It is divided into grade 1, the least severe injury defined as stretching of the lateral ligaments, without tear, grade 2, which indicates partial tearing of one or more ligaments and grade 3, the most severe sprain and classifies injuries with complete disruption of all ligaments of the lateral ligamentous complex (Halabchi & Hassabi, 2020). LAS manifests through limited ankle dorsiflexion range of motion, reduced ankle proprioception, and decreased balance (Halabchi & Hassabi, 2020). This is the most likely condition of the patient since she describes a pop sound, a feature caused by a tear of a ligament. She also reported lateral ankle pain, swelling that began after she played soccer. Subjective and objective data provide clear evidence for LAS. The right ankle pain was worse because she reportedly had a past medical history of a right ankle sprain in 2017.
Ankle Fracture: The Ottawa foot and ankle tests will help rule out the possibility of ankle fractures. According to Scheer et al. (2020), an ankle fracture presents pain and swelling around the injured bone with possible bone deformity, difficulty/inability to bear weight, and limited ROM. A twist or crack of the bone may produce a pop sound upon injury. The patient exhibits signs of ankle fracture but reported the ability to bear weight. The pain and swelling led to the possibility of this diagnosis. However, a fracture would limit weight bearing and ROM, so this diagnosis is rejected.
Achilles Tendonitis: The correct diagnosis of ATR relies on clinical examination and imaging techniques. Tests like Simmonds, Matles test, O’Brien, and Copeland tests may be used in diagnosis (Tarantino et al.,2020). It manifests with a history of pain upon injury, stiffness, and a popping sound complaint. In addition, diffuse edema and bruising are present on clinical examination. A palpable gap may be felt along the course of the tendon if the swelling is not severe, mostly 2 to 6 cm proximal to the tendon’s insertion (Tarantino et al.,2020). M.O. presented with pain, swelling and reported a pop sound upon injury. I rejected this diagnosis since, on physical exam, a palpable gap was not noted. Stiffness could have been more evident. Osteoarthritis: It is a chronic condition that involves anatomic and physiological alterations of joint tissues, including cartilage, bone remodeling, and osteophyte formation (Allen et al.,2022). Signs include pain, stiffness, swelling, and limited ROM. It can develop after a lateral ankle, acute sprain, recurrent sprains, or CAI. The patient displays symptoms similar to O.A., has a family history of O.A., and has a past medical history of ankle sprain, making this possible. Limited ROM and stiffness rule it out, which is why rejection occurs.
Ehlers-Danlos Syndrome: It is a genetic disorder affecting the connective tissues and may present differently among patients, making it difficult to isolate the syndrome. Signs include tissue fragility, generalized hypermobile joints, and excessive skin stretchiness in three areas: distal forearms, neck, knees, dorsum of hands, and elbows (Halabchi & Hassabi, 2020). Genetics is a factor in EDS. Skin elasticity is also essential in diagnosis. The patient’s skin is intact and has a good turgor. For this reason, this diagnosis was rejected.
References
Allen, K. D., Thoma, L. M., & Golightly, Y. M. (2022). Epidemiology of osteoarthritis. Osteoarthritis and Cartilage, 30(2), 184–195. https://doi.org/10.1016/j.joca.2021.04.020Links to an external site.
Chen, E. T., McInnis, K. C., & Borg-Stein, J. (2019). Ankle sprains: evaluation, rehabilitation, and prevention. Current Sports Medicine Reports, 18(6), 217–223. https://doi.org/10.1249/JSR.0000000000000603Links to an external site.
Halabchi, F., & Hassabi, M. (2020). Acute ankle sprain in athletes: Clinical aspects and algorithmic approach. World Journal of Orthopedics, 11(12), 534. https://doi.org/10.5312%2Fwjo.v11.i12.534Links to an external site.
Scheer, R. C., Newman, J. M., Zhou, J. J., Oommen, A. J., Naziri, Q., Shah, N. V., … & Uribe, J. A. (2020). Ankle fracture epidemiology in the United States: patient-related trends and mechanisms of injury. The Journal of Foot and Ankle Surgery, 59(3), 479–483. https://doi.org/10.1053/j.jfas.2019.09.016
Tarantino, D., Palermi, S., Sirico, F., & Corrado, B. (2020). Achilles tendon rupture: mechanisms of injury, principles of rehabilitation and return to play. Journal Of Functional Morphology and Kinesiology, 5(4), 95. https://doi.org/10.3390/jfmk5040095Links to an external site.
(Teldra ) Patient Information: R.J. 42 Caucasian Male
S.
CC: Low back pain
HPI: A 42-year-old Caucasian male reports intermittent pain in his lower back for the past month. He states the pain is usually a 5/10 when it happens and is currently in pain. He reports the pain as a burning, sharp pain. The pain sometimes radiates to his left leg and glutes. Denies any n/v when pain is present. He notices the pain after standing on his feet for hours at work at his family-owned farm. When he is not on his feet for a few hours, the pain is minimum, but it is aggravated by weight bearing and standing. He has taken some OTC Tylenol for the pain, which hasn’t helped much. He reports it takes the edge off for a few hours, but then the pain returns. He states, “I haven’t been to the doctor for the pain because I’ve been dealing with it. I hate going to the doctor’s office because I get nervous/anxious.” He denies being around anyone ill and denies any previous back problems.
Current Medications: Tylenol 500mg 2 tablets PO PRN every 4-6hrs for back pain; Omeprazole 20mg PO daily; Atorvastatin 80mg PO at HS for HDL; Amlodipine 5mg PO daily
Allergies: PCN (hives); seasonal allergies
PMHx: GERD; Hypercholesteremia; HTN; tetanus booster 11/2022; Flu vaccine last season 09/22; UTD on immunizations; Pfizer vaccine #1 03/05/2021 #2 3/26/2021 Pfizer booster 09/04/2022
PSHx: Lasik eye surgery 2010
Soc Hx: Married for 15 years with two kids (son and daughter), lives at home with wife and kids in a single-story home; Works on the family farm 10+ hours a day five days a week; 1PPD currently; denies any alcohol use previously and currently; denies any illicit drug uses; attends Mt. Carmel Baptist Church and has a strong support system; likes to go fishing on Saturdays.
Fam Hx: Mother-living asthma; HTN, T2DM, HDL; Father- living HTN, obesity, GERD, HDL, colon cancer; son- living Asthma, obesity; Daughter living, Asthma; M(grandmother)- living HTN, stroke, HDL; M(grandfather) HTN, T2DM, stroke, died from covid 2020; P(grandmother)-living cataracts; HTN, heart disease; P(grandfather)-living obesity, HTN, HDL, colon cancer.
ROS:
GENERAL: negative for any weight loss, fever, weakness, or fatigue.
HEENT: Eyes: Denies visual disturbances, blurred vision, double vision or yellow sclerae. Ears: denies any hearing loss, Nose: denies and nasal congestion, epistaxis, or sinus problems, throat; denies any sore throat or trouble swallowing
SKIN: Denies any rashes, lesions, or bruising
CARDIOVASCULAR: negative for chest pain, pressure, or discomfort; denies palpitations, arrythmias, denies edema, circulatory problems, or vascular problems
RESPIRATORY: Denies dyspnea, or wheezing, denies cough,
GASTROINTESTINAL: Denies any nausea, vomiting or diarrhea. No abdominal pain or blood. Denies any change in bowel habits.
GENITOURINARY: Denies painful or difficult urination, urine yellow in color odorless, last denies hematuria and flank pain
NEUROLOGICAL: denies dizziness or vertigo; denies loss of coordination, seizures, or memory loss, denies syncope or loss of consciousness
MUSCULOSKELETAL: reports back pain a 5/10 x1 month. He reports the pain as a buring, sharp pain. The pain sometimes radiates to his left leg and left gluteal. He notices the pain after standing on his feet for hours at work at his family-owned farm. When he is not on his feet for a few hours, the pain is minimum, but it is aggravated by weight bearing. He has taken some OTC Tylenol for pain relief.
HEMATOLOGIC: Denies anemia, bleeding, bruising or clotting disorder.
LYMPHATICS: Denies enlarged nodes. No history of splenectomy.
PSYCHIATRIC: Denies history depression and SI/HI, reports he gets anxiety when he has to go to the doctor
ENDOCRINOLOGIC: Denies changes in appetite, denies increase in hirst, or urination; denies heat or cold intolerances, denies thinning hair and unintentional weight loss or gain.
ALLERGIES: PCN (hives); seasonal allergies
O.
Physical exam:
Vital signs: B/P 141/76 P 86 T 98.2 RR 17 saO2 100% WT 198lbs HT 5’9 Pain 5/10
General: A/O x4, speaks full sentences, well-kept and nourished, sitting in an upright position, appears he is in pain guarding his lower back and facial grimacing. Limping noted during ambulation.
HEENT: head symmetrical, no sinus tenderness noted; sclera is white, conjunctiva moist and pick; bilateral auditory canals are pink and negative for discharge, tympanic membranes are pearly gray, no visible abnormal findings; no nasal drainage noted; throat and oral mucosa is pink and moist.
Cardiovascular/Peripheral vascular: S1 S2, negative for chest pain, no murmurs, or gallops or rubs, Radial and pedal pulses +2 bilaterally. No JVD. No edema of extremities noted. Capillary refill less that 3 seconds on BL hand and feet. No cyanosis or clubbing present. Normal distribution of hair on BL extremities.
Respiratory: Lung sounds clear, no adventitious lung sounds, no dyspnea, no sob or wheezing, chest symmetrical, negative for use of accessory muscles, no distress noted
Lymphatics: no edema or enlarged lymph nodes
Neurological: CN I-XII intact, limps on ambulation, DTRs 2+ lower extremity intact.
Psychiatric. Maintains good eye contact, answer question appropriately.
MUSCULOSKELETAL: tenderness noted to the lower back on palpitation and left gluteal, pain to lower back noted to increase when leg is extended performing the straight leg raise (SLR) lying supine. Limited ROM of the left leg. Minimal flexion of the left knee due to pain. Negative for crepitus or stiffness. Other joints are unremarkable.
Gastrointestinal: The abdomen is symmetrical, soft and non-tender to palpitation. Normoactive bowel sounds in all 4 quadrants. No mass noted.
Skin: Warm and dry to touch. No ecchymosis, rashes, or open wounds, noted. No lesions noted.
Diagnostic test/labs:
MRI of lumbar/spine and back
CT of back/spine
Xray to rule out any fractures.
CBC
Urinalysis to rule out UTI.
A.
Differential Diagnoses
Sciatic- Sciatica pain is a sharp, burning pain that radiates down the posterior and lateral leg to the foot or ankle. (Dains et al., 2019) The patient is experiencing low back pain that radiates down to his left leg and gluteal muscles. An MRI can be done to rule out nerve root compression.
Musculoskeletal Lumbar Strain- Job strain is a physical health risk factor and increases musculoskeletal pain risk. (Amiri & Behnezhad, 2020) Most episodes of low back pain are brought on by damage to the muscles, tendons, and ligaments that support the lower spine. The muscles of the hip, pelvis, buttocks, and hamstrings help the low back muscles support the lumbar spine. Sitting, walking, standing, and other actions can worsen the pain. Patients may report that rest, particularly in the supine position with the knees and hips extended, and the administration of heat or cold help to relieve discomfort. The patient standing for 10+ hours five days a week at work puts him at risk of having a possible back sprain. (Dains et al., 2019)
Spondylolisthesis- Pain can occur when the vertebral spinous process is disrupted, which causes the vertebral body to subluxate onto adjacent structures. Most of the time, this is between L5 and S1. (Dains et al., 2019). It is recognized as a common cause of low back pain, and the pain is chronic. (Rivollier et al., 2020) Due to the patient complaints of low back pain it would be appropriate to rule this condition out.
Herniated Disk- consists of back pain radiating down the buttock to below the knee, and symptoms present are more significant than a month. The actual assessment will uncover a positive SLR test result. An MRI should be considered if the pain lasts longer than a month. (Dains et al., 2019) The L4 and L5 nerve roots are often located in the involved nerve root. This patient’s employment as a farm worker puts him at increased risk because he does a lot of lifting, bending, and hard labor. (Yoon & Koch, 2021)
Vertebral compression fracture (VCF)- VCF can cause severe physical limitations, including back pain, functional disability, and progressive thoracic spine kyphosis. (Hoyt et al., 2020) Causes include trauma, osteoporosis, and systemic disease. The patient would need to have a CT, or MRI, to rule out this diagnosis. References
Amiri, S., & Behnezhad, S. (2020). Is job strain a risk factor for musculoskeletal pain? A systematic review and meta-analysis of 21 longitudinal studies. Public Health, 181, 158-167.
Dains, J. E., Baumann, L. C., & Scheibel, P. (2019). Advanced health assessment and clinical diagnosis in primary care (6th ed.). St. Louis, MO: Elsevier Mosby.
Hoyt, D., Urits, I., Orhurhu, V., Orhurhu, M. S., Callan, J., Powell, J., … & Viswanath, O. (2020). Current concepts in the m
Rivollier, M., Marlier, B., Kleiber, J. C., Eap, C., & Litre, C. F. (2020). Surgical treatment of high-grade spondylolisthesis: Technique and results. Journal of Orthopaedics, 22, 383-389.
Yoon, W. W., & Koch, J. (2021). Herniated discs: when is surgery necessary?. EFORT Open Reviews, 6(6), 526-530.