Walden University Diagnoses of The Patient Discussion

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please respond to the following discussion post 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.

SUBJECTIVE

Patient Information: AZ      Age: 46          Gender: Female

Chief Complaint: “my ankles are hurting and is uncomfortable, but my right ankle is worse, I heard it pop”

History of Present Illness:

AZ is a 46-year-old Caucasian female who was playing soccer with friends in the park who presented with bilateral ankle pains for the past 3 days.  Patient reported that she heard a “pop” sound during the game.  The right ankle hurts more than the left one and complained being uncomfortable with her discomfort.  She gave her pain a rate of 5 out of 10 and described her pain as aching one.  Patient verbalized that she is able to bear weight on it, but the pain is increasing.  She said taking Tylenol 325 mg PO helped her in her pain.

Medications:  Multivitamins 500 mg once daily

Allergies:  Pineapple – Rash (reaction)

Past Medical History:  No medical history

Past Surgical History:  None

Immunizations:  Up to date to all vaccinations; COVID vaccine completed (Pfizer dose)

Significant Family History:

Father-Hypertension

Mother-Asthma

Children-None

Maternal Grandmother-Unknown

Maternal Grandfather-Hypertension

Paternal Grandmother-Colon Cancer

Paternal Grandfather-Asthma

Sexual/Reproductive History:  Heterosexual, single, not sexually active

Social History:  Spends weekends with friends playing soccer.  Work full time as a computer analyst.  Patient denied smoking tobacco or using illicit drugs.  Patient exercises in the fitness gym 3x a week.  Patient drinks beer once a week during weekends with friends.

REVIEW OF SYSTEMS

General:  AZ is a pleasant, alert and oriented, well nourished female adult.  Patient complained of bilateral ankle pains with a pain scale of 5 out of 10 for 3 days and the right ankle’s pain is increasing.  She denied any fever, nausea, and other complaints.  AZ answered questions appropriately.

HEENT:  Denied any vision, hearing, smelling, swallowing, and head problems

Neck:  Denied any neck pain or swelling

Skin:  No itchiness or discolorations

Cardiovascular:  Denies chest pain or palpitations

Respiratory:  No shortness of breath, no cough

Gastrointestinal:  Denied abdominal pain.  Verbalized has regular bowel movements.  Last BM was this morning.

Genitourinary:  No changes in urinary pattern.  Denied any voiding difficulties

Psychiatric:  Denied any history of anxiety or depression

Neurologic:  No history of seizures, syncope or numbness.  No changes in mental patterns

Hematologic:  Denied history of anemia

Musculoskeletal:  Denied joint swelling.  Complains of bilateral ankle pains.  Verbalized that able to bear weight

OBJECTIVE

Physical Exam:

Vital signs:

B/P-129/73

Pulse-69 (strong, regular)

Respiratory rate: 14, unlabored

Temperature: 97.8 F

SPO2: 99% on room air

Height: 5’2”

Weight: 158 lbs

General:  Alert and oriented x 4, appears in mild discomfort with no immediate distress

HEENT:  Head symmetrical; Bilateral eyes reactive to light; Bilateral ears pink, no swelling; Nose has no swelling; Throat pink, no swelling

Chest/Lungs:  Clear lungs sounds, unlabored

Heart/Peripheral Vascular:  No murmurs, regular heart sounds, normal sinus rhythm; Bilateral radial and dorsalis pedis pulses (+) 2, regular

Abdomen:  Soft, non-tender, bowel sounds present in all quadrants

Skin:  Intact, dry, warm

Genitourinary:  Continent; no distention

Musculoskeletal:  Right ankle swelling, tenderness upon palpation.  Able to bear weight upon ambulation.  No crepitus present.

Diagnostic Test

CBC- normal ranges

CMP-normal ranges

Ankle xray- negative for fractures

Anterior drawer test – negative

Stress right ankle xray- (+) injured ligaments on right ankle

ASSESSMENT

Differential Diagnosis

Ankle fracture

Plantar Fascitis

Achilles Tendinitis

Anterior Impingement

Lateral Ankle Sprain

Ankle fracture is an injury to the bone which may be caused from a twisting injury from a fall or direct trauma.  These may involve the one or more of the ankle bones such as tibia, fibula, and talus with symptoms such as severe immediate pain, swelling, bruising, tenderness, deformity, and inability to bear weight (American Academy of Orthopedic Surgeons. 2022).

Plantar fasciitis is an inflammation of the fascia that connects the heel to the toes which causes intense pain to the foot.  This usually caused by chronic weight-bearing stress when laxity of foot allows the talus to slide found and medially, drop of Alcaeus, and plantar ligaments to stretch (Baumann, D., & Sheibel. 2016).

Achilles tendinitis is an inflammation of the Achilles tendon producing symptoms of pain and swelling where the tenderness inserts into the calcaneus making it harder to ambulate.

Anterior impingement is also known as foot baller’s ankle with symptoms such as pain and inflammation affecting dorsiflexion.

Lateral ankle sprain is an injury which occur from running, cutting, landing from a

jump, or from direct contact which can produce an audible tear or pop causing pain and swelling

that are immediate, but ecchymosis may lag a day or two behind (American Orthopedic Foot &

Ankle Society, 2015).  Patient’s pain is best managed with low dose pain medication for this discomfort.  Pain related to most ankle sprains can often lessen within 2 weeks, and evidence shows that nonopioid treatments like acetaminophen or ibuprofen can be more effective than opioids in managing pain (cdc.gov. 2022).  This is the primary diagnosis in which the symptoms and diagnostic results point to this diagnosis.  And patient can bear weight in this type of injury compared to the other possible diagnoses.