Respond to at least two of your colleagues on 2 different days who were assigned different case studies than you. Analyze the possible conditions from your colleagues’ differential diagnoses. Determine which of the conditions you would reject and why. Identify the most likely condition, and justify your reasoning.
SW, 46, F, Caucasian
CC: Bilateral ankle pain
HPI: SW, 46-year-old Caucasian female presents with bilateral ankle pain that started three days ago. Pt states that her right ankle is more of a concern than her left. States she was playing soccer over the weekend when she heard a “pop.” Claims she was running to kick the soccer ball when she slipped on the grass and fell on top of her right foot. She thinks she “rolled” her foot inward. States she is able to bear weight on both ankles, but the right is uncomfortable. Rates pain 7/10 in intensity for her right ankle, and 3/10 in intensity for her left ankle. She has been taking OTC 600mg ibuprofen every 8 hours for two days and has minor relief. States her right ankle pain is a 4/10 pain with ibuprofen, but only lasts a few hours. Confirms icing both ankles three times a day for the past three days. States walking, and standing is uncomfortable, and most movement makes the pain worse.
Current Medications: OTC 600mg Ibuprofen q 8 hours PRN pain
PMHx: No chronic conditions; UTD on immunizations, last TdAp 2011, last influenza vaccine 10/2020.
Soc Hx: Lives at home with her husband, 11-year-old daughter, 13-year-old son, and 16-year-old son; works as stay at home for the past 16 years; lives in a multi-family home neighborhood with several friends in the neighborhood; negative tobacco use; consumes moderate alcohol, estimates 2-3 glasses of wine per week; exercises 4 days a week and plays soccer over the weekends with her 16-year-old to help him practice; denies cell phone use while driving; not currently on birth control and LMP was 2 /12 weeks ago; practices safe sex
Fam Hx: both parents still living; mother, 68-years-old, has history of hyperlipidemia; father, 70-years-old, has a history of HTN, hyperlipidemia, and CHF; paternal grandfather died at age 80 of pancreatic cancer; paternal grandmother died at age 83 of pneumonia; maternal grandfather, 89-years-old, has a history of COPD, HTN, and CHF; maternal grandmother, 86-years-old, has a history of kidney disease; 11-year-old daughter has a history of asthma; 13-year-old son has a history of anxiety, 16-year-old son is healthy; husband, 49-years-old suffers from HTN.
GENERAL: Right ankle pain, 7/10 pain; no weight loss, fever, chills, weakness or fatigue.
SKIN: denies contact dermatitis or any other skin conditions; confirms bruising of right ankle
CARDIOVASCULAR: denies chest pain, chest pressure or chest discomfort; denies palpitations or edema
RESPIRATORY: denies shortness of breath, cough, or wheeze
GASTROINTESTINAL: denies anorexia, nausea, vomiting or diarrhea; denies abdominal pain
NEUROLOGICAL: denies headaches, head injuries, dizziness, seizures, tremors, difficulty swallowing or speaking; denies gait disturbances
MUSCULOSKELETAL: confirms right ankle pain near the right lateral malleolus; tenderness and swelling noted on right ankle; denies joint pain, stiffness, swelling, redness, or heat in upper extremities and left lower extremity; denies arthritis, hip dysplasia or scoliosis
VITALS: BP 126/72 SpO2 99% T 98.7F HR 86 RR 18 W 148 Ht 5’7”
GENERAL: No acute distress; AAO x3; patient sitting comfortably in patient chair
SKIN: no freckles, birthmarks, or other discoloration of upper extremities; dark purple bruising of right ankle noted; no discoloration of lower left extremities; CRT <3 s of all extremities; no tenting of skin
CARDIOVASCULAR: S1 and S2 audible heart sounds; no gallops, murmurs, or thrills; no edema
RESPIRATORY: no adventitious breath sounds in all lung quadrants
GASTROINTESTINAL: abdomen symmetric, rounded, no visible abnormal findings; no abdominal tenderness; no masses; normoactive bowel sounds in all quadrants
NEUROLOGICAL: steady, narrow-based gait; Romberg negative; 2+ reflexes in upper extremities and lower extremities; CN II-XII grossly intact; no focal neurological deficits
MUSCULOSKELETAL: + right ankle pain near the right lateral malleolus; + tenderness and swelling noted on right ankle; denies joint pain, stiffness, swelling, redness, or heat in upper extremities and left lower extremity; denies arthritis, hip dysplasia or scoliosis; 5/5 muscle strength in upper and lower left extremities; 2/5 muscle strength in lower right extremity; decreased ROM of right ankle, 5 degrees eversion of right foot, 10 degrees inversion of right foot, 5 degrees dorsiflexion of right foot, 20 degrees plantar flexion of right foot; decreased Rom of left foot, 20 degrees inversion, 10 degrees eversion, 20 degrees dorsiflexion, 45 degrees plantar flexion; Full ROM of upper extremities; + Ottawa ankle rules (OAR): bone tenderness at posterior edge of lateral and medial malleolus; decreased ability to bear weight on right extremity
Chen, E., McInnis, K., & Borg-Stein, J. (2019). Ankle sprains: evaluation, rehabilitation, and prevention. Current Sports Medicine Reports: June 2019. 18(6), 217-233. https:/doi.org/10.1249/JSR.0000000000000603
Common Injuries. (2019). Backpacker, 47(2), 47. https://link.gale.com/apps/doc/A575011128/EAIM?u=minn4020&sid=EAIM&xid=13250273
Curr, S., & Xyrichis, A. (2015). Does nurse-led initiation of Ottawa ankle rules reduce ED length of stay? International Emergency Nursing. 23(4), 3147-322. https://doi.org/10.1016/j.ienj.2015.01.006
Danna, N., & Brodsky, J. (2020). Diagnosis and Operative Treatment of Peroneal Tendon Tears. Sage Journals. https://doi.org/10.1177/2473011420910407
Guiney, A. (2016). Ankle Stress Views: Why, When + What. CoreEm. Retrieved from https://coreem.net/core/ankle-stress-views/#references
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