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Stress Fractures of the Foot and Ankle Essay Paper
Please give a response to those 2-discussion post with the reference separately ,make more emphasis on the social history and the deferential diagnosis.
# 1 Kelly MC.
Episodic/Focused SOAP Note Template
Patient Information:
CS, 42-year-old, Male, Caucasian
S.
CC : Low Back Pain
HPI: The patient is a 42-year-old, Caucasian male who reports low back pain that radiates down left leg for the past month.
Location: Lower Back
Onset: 1 month
Character: Sharp and radiating to left leg
Associated signs and symptoms: None
Timing: Pain is worse when sitting or standing for long periods of time. Stress Fractures of the Foot and Ankle Essay Paper
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Exacerbating/ relieving factors: Sitting or Standing for long periods of time. Pain is relieved with ibuprofen.
Severity: 8/10 pain scale
Current Medications:
Lisinopril 10mg daily
Ibuprofen 600mg every 6 hours as needed for pain.
Allergies:
No known drug allergies, no food, or seasonal allergies.
PMHx:
Hypertension was diagnosed at age 30.
Declines Influenza Vaccine
TDAP in 2022
Up to date on childhood vaccines
Declines COVID vaccines
No surgical history.
Soc Hx:
C.S works in the IT department for a community hospital. Lives alone and denies being married or having any children. Denies smoking, reports drinking socially on the weekends about 5 beers. Denies any illicit drug use. Reports joining a gym 2 months ago and exercised 3-4 days per week up until he started having back pain a month ago. He reports eating a healthy diet, trying to avoid sugars, sodium, and carbs as much as possible. Patient states he plays soccer and video games for fun. Reports seeing PCP every year for routine visits. Self-monitors blood pressure at home once a week.
Fam Hx: Mother is still alive at age 75 with a history of high cholesterol and arthritis. Father is living at age 75 with a history of hypertension and CHF.
Brother age 40 has history of high cholesterol
Maternal grandparents both deceased at young age of 40 in car accident with no known medical history.
Paternal Grandmother deceased at age 92 from pneumonia, had history of hypertension and osteoporosis.
Paternal Grandfather deceased at age 86 from hemorrhagic stroke after a fall. Had a history of dementia, arthritis, and hypertension.
GENERAL: Patient is awake, alert and oriented to person, time, place and situation, well nourished, no distress, mildly uncomfortable from lower back pain
HEENT: Eyes: Denies visual loss, blurred vision, double vision or yellow sclerae. Ears, Nose, Throat: Denies hearing loss, sneezing, congestion, runny nose, or sore throat.
SKIN: Negative for skin lesions. Denies rash or itching.
CARDIOVASCULAR: Denies chest pain, chest pressure or chest discomfort. No palpitations or edema.
RESPIRATORY: Elevated respiratory rate at 30bpm, denies difficulty breathing, coughing or shortness of breath.
GASTROINTESTINAL: Denies anorexia, nausea, vomiting or diarrhea. No abdominal pain or blood.
GENITOURINARY: No changes in bladder habits. Denies difficulty urinating or burning upon urination.
NEUROLOGICAL: Tingling and numbness to left leg. Denies headache, dizziness, syncope, paralysis, or ataxia. No change in bowel or bladder control.
MUSCULOSKELETAL: Low back pain that radiates to left leg.
HEMATOLOGIC: Denies anemia, bleeding, or bruising.
LYMPHATICS: Denies enlarged nodes. No history of splenectomy.
PSYCHIATRIC: Denies history of depression or anxiety. Denies stressors at home.
ENDOCRINOLOGIC: Denies reports of sweating, cold or heat intolerance. No polyuria or polydipsia.
ALLERGIES: Denies history of asthma, hives, eczema, or rhinitis.
O.
Physical exam:
Vitals: BP 182/94, P 102, RR 30, T 98.1, O2 99% on RA. WT 185lbs HT 70â€
GENERAL: patient appears mildly uncomfortable, holding lower back, tachypnea and tachycardic.
NEUROLOGIC: Awake, alert oriented x4, Speech is clear without facial drooping, no vision changes, follows movements. Positive slump test (Majlesi et al., 2008).
RESPIRATORY: Tachypnea, the chest expands symmetrically, no adventitious breath sounds.
CARDIOVASCULAR: Tachycardic at 102, S1and S2 sound heard. All peripheral pulses are strong and palpable +3, Negative edema to all extremities. Capillary refill is less than/equal to 3sec.
MUSCULOSKELETAL: Low back pain radiating to the left lower extremity. No evidence of trauma to affected area. Pain increases with flexion, extension, and twisting. Decreased mobility due to pain
Diagnostic results:
CT Lumbar spine
CT Pelvis
Lab work would not be necessary at this point. There is no indication of infection or abnormal electrolyte. A CT would reveal any herniating, or fracture present. Stress Fractures of the Foot and Ankle Essay Paper
A.
Differential Diagnoses:
Lumbar Disc Herniation: 80% of the population sustains an episode of low back pain. Within the vast differential of low back pain, the most common source is degenerative disc disease and lumbar disc herniation. The most common symptoms of herniation are radicular pain, sensory abnormalities, and weakness in the distribution of one or more lumbosacral nerve roots. Focal paresis, restricted trunk flexion, and increased leg pain with straining, coughing, and sneezing are also sound in these patients. Patients like MR. C.S frequently report increased pain when sitting, which is due to increased disc pressure. Local corticosteroids are a common treatment option. There are surgical options but there is no guarantee of the length of relief that will be provided (Armin et al., 2017).
Sciatica: This type of pain related to sciatica is often worsened with twisting, bending, or coughing. This is often a chronic condition that is managed through using pain medication and NSAIDs to help relive pain and inflammation. The pain is a result of the sciatic nerve. Patients experience pain and paresthesia in the sciatic nerve which is located near L4 through S2. The sciatic nerve provides motor function to the hamstrings, lower extremity adductors, and indirect motor function to the calf muscles, anterior lower leg muscles, and some intrinsic muscles (Davis et al., 2022). This is why numbness and tingling in the affected extremities occur. The nerve becomes inflamed, and the pain can resolve on its own eventually without medical treatment or NSAIDS can help with the inflammation.
Lumbar Strain: I suggested a lumbar strain because the patient joined a gym roughly 1 month before the pain began. It is easy to strain muscles while lifting weights especially if twisting is involved and proper body mechanics are not utilized. Most patients do not remember an incident occurring to cause the pain. Physical exam red flags to assess for include focal neurologic deficits, including weakness, ataxia, saddle anesthesia, decreased deep tendon reflexes, and diminished rectal tone (Sayed et al., 2022).
Ankylosing Spondylitis: This is more of a chronic condition causing spinal stiffness and pain but primarily affects the joints. This is a chronic inflammatory disease. Lab tests will assist in this diagnosis but checking a ESR and CRP. This diagnosis is not likely but cannot be excluded (Wenker & Quint, 2023).
Lumbar Compression Fraction: This is very common in patients with osteoporosis and increasing age. It is not likely that this patient has osteoporosis especially being this is a male patient. However, he does have a family history. Bone density begins to decrease after age 40 for both men and women. Though genetic predisposition and age of puberty onset play a significant role, a multitude of lifestyle and environmental factors increase the risk of developing osteoporosis (Wong & McGirt, 2013). This diagnosis is not likely but cannot be excluded as the patient is above age 40, has a family history of osteoporosis and recently joined a gym.
This section is not required for the assignments in this course (NURS 6512) but will be required for future courses.
References
1. Majlesi, J., Togay, H., Unalan, H., & Toprak, S. (2008). The sensitivity and specificity of the Slump and the Straight Leg Raising tests in patients with lumbar disc herniation. Journal of clinical rheumatology : practical reports on rheumatic & musculoskeletal diseases, 14(2), 87–91. https://doi.org/10.1097/RHU.0b013e31816b2f99Links to an external site.
2. Amin, R. M., Andrade, N. S., & Neuman, B. J. (2017). Lumbar Disc Herniation. Current reviews in musculoskeletal medicine, 10(4), 507–516. https://doi.org/10.1007/s12178-017-9441-4Links to an external site.
3. Davis D, Maini K, Vasudevan A. Sciatica. [Updated 2022 May 6]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK507908/Links to an external site.
4. El Sayed M, Callahan AL. Mechanical Back Strain. [Updated 2022 Aug 12]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK542314/Links to an external site.
5. Wenker KJ, Quint JM. Ankylosing Spondylitis. [Updated 2023 Apr 3]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK470173/Links to an external site.
6. Wong, C. C., & McGirt, M. J. (2013). Vertebral compression fractures: a review of current management and multimodal therapy. Journal of multidisciplinary healthcare, 6, 205–214. https://doi.org/10.2147/JMDH.S31659
# 2 Leyla P
Focused SOAO Template Documentation
Chief Complaint (CC): 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.
History of Present Illness (HPI): Ankle pain, reports over the weekend during a soccer game.
Pain Assessment :
1. Location: reports both ankles more on the right side.
2. Quality: reports 5 (0-10) really uncomfortable.
3. Quantity or severity: Bearing weight but uncomfortable
4. Timing, including onset, duration, and frequency: reports start over the weekend during soccer game, uncomfortable.
5. Setting in which it occurs: reports playing a soccer game.
6. Factors that have aggravated or relieved the symptom: reports rest, ice, elevate and wrapping it helped.
Medications:
• Lisinopril 10 mg orally daily.
• Tylenol 650 mg every 4 hours as needed for pain.
Allergies: denies any allergies.
Past Medical History (PMH):
• Hypertension stage I
• Past Surgical History (PSH): denies surgical history. Denies hospitalizations
Sexual/Reproductive History: Single and Sexually Active.
Personal/Social History: denies past or current tobacco use. Denies use of any illicit drugs. Denies any financial problems. Denies difficulty assessing health care and getting her medications. plays soccer every weekend.
Immunization History:
• Reports Flu vaccine this season. Stress Fractures of the Foot and Ankle Essay Paper
Significant Family History:
• Father: HTN, Hyperlipidemia.
• Mother: type 2 DM, HTN .
• Sister type 2 DM, HTN age 51
• Maternal Grandmother: HTN,Dm type 2.
• Paternal Grandmother: Colon Cancer, HTN.
• Parental grandfather: HTN, Prostate cancer.
General: Denies fatigue, Denies weakness, and Denies N/V. Denies dizziness. Denies chill or fever.
HEET: denies headache, Denies any head injury. Denies neck pain or injury. Denies glasses, denies ear pain or discomfort. Denies sore throat, denies running nose. Denies mouth pain, denies difficulty swallowing denies jaw pain.
Cardiovascular/Peripheral Vascular: denies chest pain. Denies heart palpitation. Denies edema. Denies history of blood clots or bleeding.
Respiratory: denies cough, denies SOB. Denies difficulty breathing.
Gastrointestinal: denies constipation or diarrhea. Denies abdominal pain or discomfort. Reports regular BM. Denies heartburn. Denies urination problems, Denies discomfort urinating.
Musculoskeletal: Reports pain in both ankles since the weekend, more discomfort in the right ankle, and reports bearing weight. Denies history of injury, and reports right ankle pain score 5 out of (0-10). Reports limited range of motion in both ankles on the right side more but bearing weight.
Psychiatric: denies depression or anxiety. Denies suicidal ideation.
OBJECTIVE DATA:
Physical Exam:
Vital signs:
BP Left Arm: 146/88
O2 sat: 99%
Pulse: 78
R/R: 19
Temp: 86.9 F
General: Alert-oriented and able to answer all the questions.
HEET: No abnormalities of the face, no rash, no lesion, no redness, no bruising, no flushing.
Cardiovascular/Peripheral Vascular: Symmetrical chest, capillary refills less than 3. No visible abnormalities noted.
Respiratory: chest symmetrical, no excessive use of accessory muscle while breathing. No rash, no lesion.
Gastrointestinal: abdominal symmetrical, flat, no skin abnormalities, no distension.
Musculoskeletal: no visible abnormalities of right or left arms. No edema in bilateral upper extremities, no skin lesion, no wound, no mass, no clubbing in the fingers, no pallor, no cyanosis. Edema present in both ankles, Left Ankle 1+, right +2 , reports pain 5 score (0-10), right ankle is warm to touch. No Bruising noted in bilateral ankles, skin intact. No visible abnormalities noted. Reports pain and noted Limited range of motion in the right ankle but able to bear weight. Tenderness noted in the right ankle. bilateral dorsalis pedis pulse 2+, able to move all toes bilaterally. compartment syndrome test negative.
Neurological: Alert, and answer all questions. Denies dizziness, denies lightheaded.
Diagnostic Test/Labs:
X-tray of bilateral ankles: pending report.
Differential Diagnosis
The bones and the ligaments are the main foot parts that are expected to be involved in the wound. Also, the tendons are other foot parts that are utmost probable to be involved in foot injury. The foot parts are most possible to be involved in an acute wound since the patient claims to have heard a pop sound while playing soccer.
The other symptoms that the care provider should examine include swelling tenderness and instability. Also, the patient should be explored for symptoms like bruising and limited motion. Swelling is an important symptom that should be explored because it is common when a patient suffered from sprains and fractures. In case the patient has tendon tears they should present symptoms of swelling. The presence of tenderness should identify the specific affected areas in the ankle. Tenderness should be identified through the physician doing palpation around the knee. Bruising is a symptom that indicates the presence of severe sprains in the affected area and also fractures. Instability is a symptom that should be explored because it indicates whether the patient has a ligamentous injury in their ankle. Fracture and inflammation should be confirmed by analyzing the presence of limited motion.
The first differential diagnosis for ankle pain is ankle sprain, which is caused by the tearing or stretching of ankle ligaments. Moving out the ankle out of its normal position is what causes a sprain in the ankle. Therefore, the ankleâ€s ligaments are caused to tear partially or completely or even stretch. The stretching and tearing of the ligament therefore cause pain in the ankle and thus ankle pain can be due to ankle sprain.
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Another differential diagnosis is tendonitis or tendon tear, which causes inflammation and pain in the ankle. It is characterized by a rate of breaking down that is more than the tendonâ€s ability to rebuild. Tendonitis is therefore the inflammation caused by macro tears or breakdown, which is more than the tendonâ€s ability to rebuild (Varcallo et al., 2020). A tear can also acquire due to inflation, which causes the tendon to fail. Therefore, the ankle pain can be due to tendonitis or tear hence the differential diagnosis.
The patient might also be having a fracture, which is the most common cause of ankle pain. Breaking down bones or a bone n the ankle joint is what causes the ankle fracture to occur. Therefore, pain in the ankle might be indicating that the patient got their ankle bones broken and thus they suffer from a fracture.
Stress fractures are another differential diagnosis that is caused by continually applying mechanical pressure on the ankle bones (Ellis, 2019). The diagnosis is possible in the patient because they play soccer and thus they might continually place force on their ankle causing a stress fracture. It is characterized by the breakdown of the bone but it remains in its position and it causes pain.
Planter fasciitis is the last differential diagnosis, which is caused by the fibrous tissue being inflamed. The complication causes the heel to suffer intense pain. Therefore, ankle pain can be used as an indicator of plantar fasciitis.
The physical examination that I would perform includes an inspection to identify bruised and palpitations feel tenderness. I would also perform a stability test to check the stability of the ligaments and the ankle. Another physical examination I would perform is the evolution of the movement of the ankle and if there is any limitation.
The special maneuvers I would perform include X-rays to identify if there are any dislocations and fractures. I would also perform a bone scan to check for damages and abnormalities in the ankle bones. I would also use an MRI to depict ligament tears and injuries that cause ankle pain.
Using the Ottawa ankle rules to determine if there is a need for additional testing. The Ottawa is essential in ruling out clinically significant ankle fracture sand foot structure so that additional testing such as the use of X-ray is reduced (Dr. Stiell, 2023). Therefore, I would use the rules to avoid doing more tests.
References
Dr. Stiell, I. (2023). Ottawa Ankle Rule. https://www.mdcalc.com/calc/1670/ottawa-ankle-ruleLinks to an external site.
Ellis, S., J. (2019). Stress Fractures of the Foot and Ankle.
https://www.hss.edu/conditions_stress-fractures-foot-ankle.asp#:~:text=Stress%20fractures%20are%20common%20in,(become%20%22displaced%22)Links to an external site..
Varacallo, M., Bitar, Y., & Maier, S. (2020). Rotator cuff tendonitis – statpearls – NCBI bookshelf. https://www.ncbi.nlm.nih.gov/books/NBK532270/. https://www.ncbi.nlm.nih.gov/books/NBK532270/ Stress Fractures of the Foot and Ankle Essay Paper
