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 can 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 Ottawa ankle rules to determine if you need additional testing?
NURS6512 Discussion- Week 8
Episodic/focus SOAP Note Template
Case 1: Back Pain
Patient Information
Initials: H.H Age: 42 Gender: Male. Race: Caucasian
SUBJECTIVE DATA:
Chief Complaint (CC): “Lower Back Pain”
History of Present Illness (HPI): Patient is a 42-year-old white male who developed lower back pain that has been bothering him for the past month. He states that the pain radiates to his left leg sometimes, and it increases with sitting for a long period of time but gets better when standing. Severity of pain is 7/10 on pain scale of 0/10.
Current Medications: OTC Ibuprofen 300mg 2 tablets every 6hours PRN for Lower back pain.
Amlodipine 10mg 1 tab PO daily for hypertension
Allergic/Immunologic: No known drug, food seasonal, latex/rubber allergies
Past Medical History (PMH): Lower Back Pain
Past Surgical History (PSH): None
Sexual/Reproductive History: Single with no kids.
Personal/Social History: Patient works at a storage company as an assistant manager. He enjoys hiking, surfing, and skiing. He reports drinking alcohol on rare occasions, denies illicit drug use and smoking tobacco. He reports a healthy lifestyle including lifting weights three times a week and eating a high protein and low carb diet.
Immunization History: Influenza 11/1/2020, Pneumovax 05/2020. Tetanus-Unknown
Significant Family History:
Father: Father is 79 and still living. He has Hypertension, diabetes type 2, and asthma.
Paternal Grandmother: She had hypertension and died at the age of 85.
Paternal Grandfather: Died at the age of 80, had asthma.
Mother: His mother is still alive and has diabetes type 2.
Maternal Grandfather: Died at the age of 80, had type 2 diabetes.
Maternal Grandmother: Died at the age of 85, had a stroke.
Sister: Age 45, has type 2 diabetes.
Review of Systems:
General: The patient is alert and oriented to person, place, time and situation, appropriately dress according to the weather, good judgement, and a well-nourished Caucasian male. No distress noted but mild discomfort due to pain in his lower back radiating to his left leg. His emotional and behavioral needs are appropriate at the present time considering patient’s clinical condition. Denies current home stress and abuse.
HEENT:
· Eyes: Patient denies itching eyes or discharges, uses glasses but does not use contact lens, and denies blurred vision.
· Ears: He denie
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