Make a SOAP Note Not a narrative essay: Ankle Pain

Note:  Your Discussion post should be in the SOAP Note format, rather than the traditional narrative style Discussion posting format. Refer to the Comprehensive SOAP Template in the attachments below for guidance.

CASE: 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. In determining the cause of the ankle pain, based on your knowledge of anatomy, what foot structures are likely involved? What other symptoms need to be explored? What are your differential diagnoses for ankle pain? What physical examination will you perform? What special maneuvers will you perform? Should you apply the Ottowa ankle rules to determine if you need additional testing?

 

To prepare:

With regard to the case study you were assigned:

·         Review this week’s Learning Resources, and consider the insights they provide about the case study.

·         Consider what history would be necessary to collect from the patient in the case study you were assigned.

·         Consider what physical exams and diagnostic tests would be appropriate to gather more information about the patient’s condition. How would the results be used to make a diagnosis?

·         Identify at least five possible conditions that may be considered in a differential diagnosis for the patient.

Address all these in the SOAP Note not an Narrative Essay (Follow the SOAP Note Template on the attachment):

1.     A description of the health history you would need to collect from the patient in the case study to which you were assigned.

2.     Explain what physical exams and diagnostic tests would be appropriate and how the results would be used to make a diagnosis.

3.     List five different possible conditions for the patient’s differential diagnosis, and justify why you selected each.

4.     Include how the patient X-ray (in the attachment below)  helped you to refine the differential diagnosis

5. Please address also all the questions on the case above in the SOAP note.

 

REMINDER:Please make a SOAP NOTE for this case. Make your own patient’s data, applicable health history, review of systems, P.E., labs, differential diagnosis, final diagnosis etc. Incorporate the data from the case in the SOAP note that you will do… This is not a narrative essay ok…. I need SOAP note (Nurse Practitioner/RN/MD  makes SOAP note)… Be guided with the SOAP Note in the templates/exemplar… Don’t copy paste. Formulate your own… Don’t forget to cite the Five different possible conditions (Differential diagnosis) and have Reference lists too.

 

Resources:

·         Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2015). Seidel’s guide to physical examination (8th ed.). St. Louis, MO: Elsevier Mosby.

o    Review of Chapter 4, “Vital Signs and Pain Assessment” (pp. 50-63)

o    Chapter 21, “Musculoskeletal System” (pp. 501-543)

This chapter describes the process of assessing the musculoskeletal system. In addition, the authors explore the anatomy and physiology of the musculoskeletal system.

Dains, J. E., Baumann, L. C., & Scheibel, P. (2016). Advanced health assess