Assessment
Respond to at least two of your colleagues on 2 different days who were assigned different case studies than you. Analyze the possible conditions from your colleagues’ differential diagnoses. Determine which of the conditions you would reject and why. Identify the most likely condition, and justify your reasoning.
Post 1
Sendy Jean Baptiste
Ankle pain
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Patient Information:
GP 46 yo black female
S.
CC Ankle pain
HPI: 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.
Location: both ankles
Onset: 3 days ago
Character: pressure, aching.
Associated signs and symptoms: pain,
Timing: while playing soccer over the weekend, she heard a pop.
Exacerbating/ relieving factors: Acetaminophen makes the pain better from 7/10 to 4/10
Severity: 4/10 pain scale
Current Medications: Acetaminophen 650 mg OTC for the past 3 days. Daily multivitamins OTC
Allergies: NKA
PMHx: sprained right ankle last July 2021, UTD on immunizations, covid vaccine #1 7/19/2021 Pfizer; Covid vaccine #2 9/01/2021 Pfizer Soc Hx: Single with 3 children 2 boys (twins) 18 yo and a girl 16 yo. High school PE class trainer. Denies smoking, drinks a glass of wine occasionally. Loves playing sports and loves to travel with family.
Fam Hx: Dad decease in a car accident 12 years ago, mom has a history of HTN and hyperlipidemia, both paternal grandfather and paternal grandmother died of cancer. The maternal grandmother has a history of hypertension and hyperlipidemia, the maternal grandfather has a history of CAD, rheumatoid arthritis. All of her children are healthy with no medical issues.
GENERAL: Denies weight loss, fever, chills, reports weakness and fatigue.
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: Denies rash or itching.
CARDIOVASCULAR: Denies chest pain, chest pressure, or chest discomfort. No palpitations or edema.
RESPIRATORY: Denies shortness of breath, cough, or sputum.
GASTROINTESTINAL: Denies anorexia, nausea, vomiting, or diarrhea. No abdominal pain or blood.
GENITOURINARY: Denies burning on urination. Pregnancy. Last menstrual period unknown.
NEUROLOGICAL: Denies headache, dizziness, syncope, paralysis, ataxia, numbness, or tingling in the extremities. No change in bowel or bladder control.
MUSCULOSKELETAL: Ankle pain (both), denies back pain.
HEMATOLOGIC: Denies anemia, bleeding, or bruising.
LYMPHATICS: Denies enlarged nodes. No history of splenectomy.
PSYCHIATRIC: Denies history of depression or anxiety.
ENDOCRINOLOGIC: Denies reports of sweating, cold, or heat intolerance. No polyuria or polydipsia.
ALLERGIES: Denies history of asthma, hives, eczema, or rhinitis.
O.
VS: BP 106/82; P 64; R 18; T 96.9; 02 100% Wt 152lbs; Ht 76”
General: Right ankle swollen, unable to walk straight, capillary refill within 3 seconds, no abnormal findings in the left ankle.
HEENT: No redness to eyes, Nose clear, symmetric, pink/reddish mucosa. Throat pink, and moist.
SKIN: No signs of rash
CARDIOVASCULAR: no murmurs or abnormal heart sounds auscultated.
RESPIRATORY: No respiratory distress, lungs are clear.
GASTROINTESTINAL: Bowel sounds normoactive, no guarding.
GENITOURINARY: Urine clear and yellow.
NEUROLOGICAL: Cranial nerves present, no sensitivity to light.
MUSCULOSKELETAL: abnormal gait noted due to right ankle injury.
LYMPHATICS: no swelling lymph nodes palpated.
Diagnostic results: X-rays. Doctors use X-rays to rule out a foot fracture or an ankle dislocation. X-rays can also detect arthritis of the foot and the ankle, which can cause pain and swelling.
Anterior drawer test: To assess for ankle instability.
Talar tilt test (or inversion stress maneuver): To assess the integrity of the calcaneofibular ligament
Ottawa Ankle Rules: The Ottawa ankle rules are used to predict whether an x-ray is indicated for a patient presenting with ankle pain. Location of the pain over the malleoli and the ability to bear weight is important in this determination Lau et al. (2018).
A .
Differential Diagnoses
Ankle Sprain:
According to Dains, J. E., Baumann, L. C., & Scheibel, P. (2019), ankle sprain (Inversion or Eversion) The most common mechanism of ankle injury is an inversion force that stresses the lateral ligamentous support of the joint. The lateral ligaments are of greater length than the medial ligaments and are more predisposed to injury. An audible pop or tear implies a rupture or tear of the ligament. Swelling of the ankle within minutes of injury indicates bleeding and soft tissue trauma. Patients with a ligamentous injury will generally be able to walk and bear weight on the injured foot even though it may be uncomfortable. Examine the injured joint by palpating the course and attachment points of the ligaments and perform joint ROM to test for ligamentous integrity.
Sprains cause minimal to moderate pain, increasing 1 to 2 days after the trauma when the inflammatory process begins. A complete disruption that severs the sensory nerve fibers within the structure will cause little pain, whereas a partial injury irritates sensory fibers, and may produce intense pain.
Achilles tendon rupture:
The Achilles tendon is a strong fibrous cord that connects the back of the calf to the heel. Overstretching this tendon can lead to partial or complete (rupture) tear. It is often an injury in recreational sports. Patients will report a jumping, falling, or stepping injury and hearing a pop followed by a sharp pain in the ankle and difficulty ambulating. The patient will not be able to stand on the toes with the affected limb. Ankle swelling may be present.
Ankle injury:
According to Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019), ankle injuries are defined by the kind of tissue — bone, ligament, or tendon — that’s damaged. The ankle is where three bones meet — the tibia and fibula of your lower leg with the talus of your foot. These bones are held together at the ankle joint by ligaments, which are strong elastic bands of connective tissue that keep the bones in place while allowing normal ankle motion. Tendons attach muscles to the bones to do the work of making the ankle and foot move and help keep the joints stable.
Calcaneus Fracture: A fracture of the calcaneus, or heel bone, can be a painful and disabling injury. This type of fracture commonly occurs during a high-energy event.
Subtalar Dislocation: Subtalar dislocation is the disruption of the articulation of both the talocalcaneal and the talonavicular joints with an intact ankle joint mortis.
P.
This section is not required for the assignments in this course (NURS 6512) but will be required for future courses.
References
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Seidel’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby.
Dains, J. E., Baumann, L. C., & Scheibel, P. (2019). Advanced health assessment and clinical diagnosis in primary care (6th ed.). St. Louis, MO: Elsevier Mosby.
Lau, B. C., Moore, L. K., & Thuillier, D. U. (2018). Evaluation and management of lateral ankle pain following injury. JBJS Reviews, 6(8), e7-e7. /orders/doi.org/10.2106/jbjs.rvw.17.00143
Sullivan, D. D. (2019). Guide to clinical documentation (3rd ed.). Philadelphia, PA: F. A. Davis.
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Post 2
Justin Wilt
Review of case study 3
Top of Form
Patient Information:
AB, 15 yo., Caucasian male
S.
CC- “Dull ache in both knees, and sometimes a clicking in the knees.”
HPI: The patient is a 15 yo Caucasian male presenting to the clinic with report of dull pain, which he reports to be a 5/10, in both knees. There is also a click in one or both knees and a catching sensation under the patella. The patient reports difficulty walking and concentrating when the pain and the sounds occur. The symptoms usually express themselves after walking long distances or sometimes standing too long before sitting down, which usually occur in the daytime. The patient takes either 650 mg Tylenol or 500 mg ibuprofen for the pain, depending on which is available. He feels that Tylenol and ibuprofen dull the pain but do not totally alleviate the pain.
Current Medications: Ibuprofen 500 mg and Tylenol 650 mg PRN.
Allergies: NKA
Past medical hx (PMH): No previous medical history to report,
Past surgical hx (PSH)- Patient reports a history of torn rotator cuff.
Soc hx: Patient does not use tobacco products, alcohol, or illicit drugs. He is the starting 140-pound wrestler on his high school team. He lives with his biological parents and has a younger sister (12 yo). He occasionally works for local farmers doing jobs such as bailing hay, mowing, and feeding livestock. He enjoys going to the local mall with his friends to hang out and skate in the parking lot.
Immunizations- COVID vaccination (Moderna) 10.23/2021, current flu shots.
Fam hx: Father: 38 yo with a history of Osgood-Schlatter disease; Mother: 36 yo with no previous medical history; Sister: 12 yo with no previous medical history; Maternal grandmother obesity, HTN; Maternal grandfather HTN, obesity, knee replacement age 58; Paternal grandmother died of cancer age 63; Paternal grandfather HTN.
ROS:
General: Patient reports no fatigue, cough, fever, or chills. Denies problems sleeping. He has not had any recent weight loss or appetite change.
HEENT: Patient denies headaches, dizziness, or confusion. Patient denies problems hearing, tinnitus, or discharge. Patient denies issues with vision or itching, dryness, or pain in the eye. Patient denies epistaxis, pain, or trouble breathing through his nose. Patient denies soreness in throat, difficulty swallowing, or problems talking. Patient has no pain in the mouth, problems chewing, or changes in taste. Patient denies neck pain, stiffness, or limited ROM.
Cardiovascular: Denies palpitations, chest pain, SOB, or irregular heartbeat.
Respiratory: Patient denies cough, difficulty breathing, SOB, or dyspnea upon exertion.
Gastrointestinal: Denies N/V. No changes in bowel movement.
Musculoskeletal: Expresses normal ROM.
Psychiatric: Patient has no history or present diagnosis of psychiatric disorders. Denies depression, anxiety, SI or HI.
Physical exam:
Vital Signs:
Blood pressure: 118/76
spO2: 100% room air
HR: 62 bpm
Resp. rate: 14
Temp.: 36.8 Celsius
HEENT- Patient does not have headaches or altered sensorium. Eyes are clear, moist conjunctiva, no diplopia, does not wear glasses. Ears equilateral, no hearing loss, tinnitus, or abnormalities. Mouth has no lesions, gum abnormalities, tooth decay, or bleeding. Throat is pink, no swelling, and no pain reported.
Respiratory- No crackles, rhonchi, or stridor heard during auscultation. Even, unlabored breathing.
Cardiovascular- No murmurs, rubs, gallups, or abnormal heart rhythm detected during auscultation.
Gastrointestinal- Normal bowel sounds heard in all quadrants during auscultation. Kidneys and spleen not palpable.
Skin- No lesions, wounds, or lacerations found during assessment. Warm, dry, and intact.
Musculoskeletal- No swelling, pain, or stiffness in the joints. Normal ROM.
Neurological- No neuropathy and neuro checks are normal. Alert and oriented X4. Speaks well.
Diagnostic tests- valgus and varus test (medial and lateral ligament), posterior drawer test (posterior crucial ligament), Lachman test (anterior crucial ligament, anterior drawer test (anterior crucial ligament), pivot shift test (anterior crucial ligament), McMurray test (menisci), arthrometric testing, x-ray, and CT scan.
A .
Meniscal injury- damage to the knee cartilage that provide cushion between the tibia from the femur. Pain, swelling, and locking of the knee joint are hallmarks of this injury. Usually resolved by rest, ice, pain relievers and sometimes surgery (Kraus et al., 2012).
Medial collateral ligament injury- damage to the ligament locate on the inner side of the knee that usually sounds like a pop. Swelling, pain, and a feeling that the knee may “give way” are hallmarks of this injury. Usually resolved by rest, ice, compression, and elevation (RICE) (Hoetzel et al., 2014).
Anterior crucial ligament injury- tissue that connects the femur to the tibia at the knee. Pain and swelling usually followed by inability to move normally or make sudden twists or turns. If it is a full tear surgical intervention is imminent, otherwise physical therapy may be an option (Kraus et al., 2012).
Osgood-Schlatter disease- affects children with growth spurts, especially active children playing sports. There is usually a painful lump below the kneecap that usually resolves on its own (Jones et al., 2000).
Sinding-Larsen-Johansson syndrome- swelling and irritation of the growth plate at the bottom of the knee characterized by swelling, tenderness around the kneecap, or pain that increases with activity or squatting. Usually treated with ice, OTC medication, or physical therapy (Hoetzel et al., 2014).
P.
This section is not required for the assignments in this course (NURS 6512) but will be required for future courses.
References
Ball, J.W., Dains, J.E., Flynn, J.A., Solomon, B.S., & Stewart, R.W. (2019). Head and neck: Key
points. In Seidel’s guide to physical examination: An interprofessional approach (9th ed.).
St. Louis, MO: Elsevier Mosby.
Hoetzel, J., Preiss, A., Heitmann, M.A., & Frosch, K.H. (2014). Knee injuries in children and
adolescents. European Journal of Trauma and Emergency Surgery, 40(1), 23-36.
Jones, D., Louw, Q., & Grimmer, K., (2000). Recreational and sporting injury to the adolescent
knee and ankle: Prevalence and causes. Australian Journal of Physiotherapy, 46(3),
179-88.
Kraus, T., Svehlik, M., Singer, G., Schalamon, J., Zwick, E., & Linhart, W. (2012). The
epidemiology of knee injuries in children and adolescents. Archives of orthopaedic and
trauma surgery, 132(6), 773-779.
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