SOAP Note – 5

Nikki Tacsik
12/11/20
NURS7027 – Infant, Child, & Adolescent Health Practicum

Subjective:
Chief Complaint: 12-year-old presents to office with ankle pain and swelling x3 days
History of Present Illness: Patient presents to the office on 12/7/20 with mother with
complaints of left ankle pain and swelling x3 days. Patient was running around outside on
Friday and tripped over his ankle and fell. Patient states that walking hurts his ankle, but
resting makes it better. His mother has given him motrin for pain and it has also helped some.
The pain is all in his left ankle and does not radiate. It has been on-going since Friday, but
intermittent with rest and activity. It mostly feels sore and achy, but more sharp pain when
walking on it. It hasn’t gotten worse per the patient and his mother, but the patient is having a
hard time walking on it and it does not seem to be getting better. The patient has never had
anything like this before, but the mom is concerned he may have broken his ankle.
General Medical History:
Medical: asthma (2013 – well controlled with medications), strep throat (has tonsillectomy)
Surgical: tonsillectomy (2015 – no complications)
Medications: Pulmicort 180 mcg/puff 2 puffs bid, albuterol 2.5mg/3ml qid PRN for
wheezing
Allergies: NKA
Family History: Mother is alive with a history of high cholestrol. Father is living with no
significant medical history. Maternal grandfather is alive with no significant PMH. Maternal
grandmother is living with a history of diabetes. Paternal grandmother is alive with a history
of stroke. Paternal grandfather is alive with a history of lung cancer. Patient has 2 siblings
with no significant PMH.
Social History: Mother’s history: G4T3P1A0L3. Patient attends 6th grade via zoom classes
currently at a local middle school. He plays basketball, baseball, and football (some sports
paused now d/t COVID). He enjoys playing with his friends and being outside. Occasionally
plays video games but family spends a lot of quality time together – family game nights,
going out to dinner, etc. they travel to Florida once or twice a year to visit his dads’ parents
where they reside. He has 1 dog at home, too, who he enjoys playing with. He denies any
smoking or drinking. He states he attended a program in school that talked about the bad
effects of drugs and alcohol.
Review of Systems:
General Constitutional: Positive for pain in L ankle. Denies weight changes, fever, chills,
fatigue, or night sweats.
EENT: Denies discharge from eyes or ears, cough, problems swallowing, or sore throat.
Skin: Denies any changes in overall skin texture or other new lesions. Denies new moles,
pruritis, or rashes.
Respiratory: Positive for history of asthma but denies any flare ups. Has not needed albuterol
recently. Denies cough, wheezing, fast respiratory rate, or shortness of breath.
Cardiovascular: Denies palpitations or edema.
Gastrointestinal: Denies constipation, diarrhea, or abdominal pain.
Endocrine: Denies excessively dry or sweaty skin.
Neurologic: Denies headaches, or extremity weakness.
Objective:
Weight: 90 lbs 2 oz Height: 59.3 in BMI: 22 (healthy weight)
Vital Signs: T 98.9 tympanic, P 86, RR 22, BP 106/72, SpO2 99% on RA
Constitutional: Well appearing afebrile pleasant 12-year-old Caucasian male. Patient is
dressed appropriately for weather and is well groomed and clean. Relaxed on exam table with
mother in side seat.
HEENT: Normocephalic and symmetrical head. Trachea midline without lymphadenopathy.
Pupils equal, round, and reactive to light. Sclera white and conjunctiva pink. Oral mucosa
pink and moist. No swelling in throat. Has full set of permanent teeth. Gums pink and moist.
Skin: Skin smooth, dry, and warm with no nodules, lesions, or ulcers observed. Bruising to L
medial ankle but skin intact.
Respiratory: Respirations unlabored. Chest expansion equal bilaterally. Lungs clear in all
fields. No wheezes, rhonchi, crackles, or pleural rubs noted
Cardiac: Regular rate and rhythm. S1 and S2 heard. No gallops, rubs, or clicks. Innocent
murmur.
Abdomen: Bowel sounds active in all 4 quadrants. Abdomen rounded, symmetrical, soft, and
nontender.
Musculoskeletal: No edema to BUE or RLE noted. Equal strength bilaterally in upper
extremities. LLE swollen 2+ edema non pitting and ROM weak in LLE. Slight limp when
walking on LLE.
Neurological: Alert to person, place, time, and situation as appropriate for age. Sensory and
motor function intact in RLE and BUE. Decreased ROM in LLE due to pain.
Assessment:
Patient presents with mechanical fall and ankle pain and swelling x3 days. Denies any other
symptoms such as fever, chills, open wounds, or loss of sensory function. Slight decrease in
ROM on LLE and positive for 2+ non pitting edema. Pedal pulses and doralis pedis pulses 2+
bilaterally. No redness or tenderness to touch, but pain with movement of L ankle. No open
wounds. Possible fracture to ankle but most likely soft tissue injury such as a sprain/strain.
Differential Diagnosis:
1. Sprain/strain to L ankle**
2. L ankle fracture
3. DVT
4. Cellulitis
Plan:
Since there is no open wound and there was no penetrating trauma to the left angle of the
patient I doubt Cellulitis. There is also no redness which would indicate Cellulitis. There is
some bruising on the medial aspect of the left angle. I also doubt DVT because of the
patient's history of present illness. There is no calf tenderness and pulses are equal bilaterally.
Also, DVT's are unlikely in a child his age with no significant history and that is active. Will
obtain an X Ray to rule out a fracture and go from there.
Diagnostic Testing:
Xray L ankle – nondisplaced fracture of medial malleolus
Treatment:
Informed patient and mother that patient does have a small fracture period since it is non-
displaced it can usually be treated pretty easily, but since he does have a fracture I will refer
him for further treatment to an orthopedist. Gave the patient a walking boot Ann instructed
him to keep all weight off of his left ankle until he sees the orthopedist and he gives him
further instructions. Instructed patient and mother on RICE treatment. Rest, ice, compress,
and elevate LLE. Continue with Tylenol and motrin as needed for pain - can interchange
then to keep up with the pain schedule and for breakthrough pain. Will defer all other meds
and treatment to the orthopedist to prevent any further complications. Instructed patient and
mother that the orthopedist’s office will call the mother to schedule an appointment as soon
as possible. Follow up regarding the ankle fracture can be done with the orthopedist but if
any other complications or new symptoms arise instructed mother to make an appointment
with us. If pain , swelling where is sensory and motor function get significantly worse
instructed mother to take patient and to go to the ER. can review orthopedist treatment an
overall follow up at next patient visit.