Episodic/Focused SOAP Note Template

Case study #2

Patient Information:

Initials, Age, Sex, Race

S.

CC: Pt both of her ankles are in pain, but her right ankle aches more.

HPI: A 46-year-old female patient complains of discomfort in both ankles, with the right

ankle hurting the most and popping when playing soccer. With some pain, the patient may

carry weight.

Location: symmetrical ankles

Onset: this past weekend

Character: uncomfortable

Associated signs and symptoms: ambulation

Timing: during soccer practice

Exacerbating/ relieving factors: when bearing body weight on feet

Severity: No pain level mentioned

Current Medications: not stated

Allergies: NKDA

PMHx: Not stated

Soc Hx: Not stated.

Fam Hx: Not stated

Life style: Physically fit. Active in sports, plays soccer active.

Questions for patient: The place of the pain? From 0 to 10, with 10 being the most severe

pain, rate your level of discomfort. What worsens or lessens your pain? When you heard the

pop, what were you doing? How long have you been experiencing ankle pain? Have you ever

suffered from ankle injuries?

OBJECTIVE DATA:

Review of system (ROS)

GENERAL: No weakness or weariness, no weight loss, no fever, chills, or difficulties

bearing weight on the right ankle while walking.

HEENT: no difficulties

SKIN: undamaged

CARDIOVASCULAR: No complaints of chest discomfort or palpitations

RESPIRATORY: There was no mention of breathlessness

GASTROINTESTINAL: No reports of stomach discomfort

GENITOURINARY: No urinary complications reported

NEUROLOGICAL: There were no reports of headache, nausea, vomiting, syncope,

paralysis, ataxia, numbness, or tingling in the extremities.

MUSCULOSKELETAL: Ankle pain on both sides of the lower extremities. The worse ankle is

the right one.

HEMATOLOGIC: There was no anemia sign, bleeding, or bruises.

LYMPHATICS: No inflamed nodes.

PSYCHIATRIC: No record of hopelessness or anxiety.

ENDOCRINOLOGIC: There have been no complaints of cold, heat, or perspiration. No

polydipsia or polyuria.

ALLERGIES: No previous history of rhinitis, hives, asthma, or eczema.

Physical exam: The ankle and foot bones will likely be affected during the physical

examination of this patient. The Achilles tendon, calcaneus, malleolus, deltoid ligament,

tarsal joint, a portion of the lower tibular and fibular, and the ankle joint subtalar joint are

among them. The ankle is specifically identified by the ankle joint, medial malleolus, lateral

malleolus, and Achilles tendon. (Jarvis, 2018)

Diagnostic results: Ankle x-rays of both lower extremities will be performed as part of the

diagnostic procedures. - Bone x-rays are used to assess bone connection, erosion, and texture.

Ct scan that clearly shows a particular bone plane that is affected, in this example the ankles.

Another diagnostic test is an MRI, but only when it is required. I'll probably do physical

exams to look for heat, swelling, redness, and soreness. Palpate the medial and lateral

malleoli, the anterior ankle surface, and the Achilles tendon. Additionally, the patient will be

given instructions to do dorsiflexion, plantar flexion, eversion, and inversion. The Ottawa

Ankle Rules, which aid in identifying the traits of patients requiring a series of ankle

radiographs in situations of acute ankle injury, may also be used. (Ford et al.,2005)

Differential Diagnoses:

1. A possible ankle strain includes damage to the muscles and tendons, and it might sound

like it's ripping or tearing (Jarvis, 2018). A case study example, the pt. claims that she heard a

"pop." Its severity might vary from slight tearing to total destruction. Generally, injuries are

categorized as mild, moderate, or severe. When lateral tension is applied when the joint is in

plantar flexion, ankle injuries often result. I don't play soccer, but now that the world cup is in

progress, I can confidently say based on my understanding of anatomy that players' ankle

joints are plantar flexed when playing soccer.

2.Another scenario is a potential ankle sprain, which includes damage to the ligamentous

components and may sound like ripping or tearing as in the case study. Sprains have mild to

moderate pain that becomes worse 1–2 days after the injury when the inflammatory process

kicks in.

3. The possibility is a fracture, which manifests itself shortly after damage by producing

widespread swelling surrounding the injured bone. The fracture will have deformity if it is

displaced. It isn't in this instance. A patient may describe hearing a snap and experiencing

increasing discomfort while bearing weight or moving a limb (Jarvis, 2018).

4. Potential Achilles tendon injury: The typical symptoms include lower calf discomfort that

comes on suddenly and the difficulty to stand on the afflicted side's toes. (Ford et al., 2005)

5. post-exercise muscle soreness: This condition manifests as weakness and reduced strength

in the distal section of the skeletal muscles after physical activity that the person is not used

to.

P.

Not applicable currently

References:

Ford, M. J., Hennessey, I., & Japp, A. (2005). Introduction to clinical examination. Elsevier Health

Sciences.

Jarvis, C. (2018). Laboratory Manual for Physical Examination and Health Assessment, Canadian

Edition-E-Book. Elsevier Health Sciences.