Focused SOAP Note for a patient with ankle pain

Focused SOAP Note for a patient with ankle pain example, includes subjective, objective, assessment, and plan sections.

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Focused SOAP Note for a patient with ankle pain

Patient information

Name: RN Gender: female Age: 46 Race: Caucasian

S:

CC: “I feel a lot of pain in my ankle, particularly the right ankle.”  

HPI: the patient is a 46-year-old woman who came to the clinic with the chief complaint of ankle pain, notably in her right ankle. She reported hearing a \”pop\” sound while playing soccer over the weekend. Pt can bear weight, but with some pain. She has not yet sought pain relief treatment.

Medications: None

Allergies: She did not report any drug/ food allergies

PMH: None reported

PSH: None reported

Social History: None provided

Significant Family History: None provided

Lifestyle: She reported taking part in soccer during the weekends

Additional questions for the patient: Can you pinpoint the location of your pain? On a scale of 0 to 10, where 10 is the worst agony you\’ve ever experienced, how would you evaluate your pain? Is there anything that makes the pain go away or get worse? When did all of this start? What were you doing when you heard the \”pop,\” sound? How long have you been battling ankle pain? Do you have a history of ankle injuries?

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O:

ROS:

Constitutional: Denies fever and exhaustion, as well as trouble bearing weight on the right ankle during ambulation.

CV: Not provided

GI: Not provided

MSK: bilateral ankle discomfort with increased right ankle discomfort while ambulating.

Psychiatric: Not provided

Skin: Not provided

Endocrine: Not provided

Physical exam

Vital signs: not provided

A:

Differential Diagnosis:

1. Primary diagnosis: Ankle sprain: Athletes are highly vulnerable to ankle sprains, and they typically present with pain after a notable injury, but with the capacity to bear weight, perhaps with some pain(Miklovic et al., 2018).

 2. Ankle fracture: The most typical signs of an ankle fracture include throbbing pain with incapacity to ambulate, as well as bruising, edema, and difficulty bearing weight.

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3. Achilles tendon injury: The injury causes pain above the heel, especially when the ankle is stretched when standing. It might be minor at first and become better or worse with time. When a tendon ruptures, the pain is instantaneous and intense (Lemme et al., 2018).

4. Navicular fracture: This form of the fracture causes navicular discomfort to the dorsum of the heel, often medially along the arch, which intensifies with physical exercise.

 5. Post-exercise muscle soreness: This type of injury manifests as pain in the distal region of muscle tissue following unfamiliar physical exercise, as well as an impaired range of motion (Afonso et al., 2021).

PLAN: Considering the patient has an ankle sprain, I will recommend RICE therapy with a follow-up appointment in a few weeks (Calin et al., 2019).

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Ankle Pain

The lateral ankle complexity is most often affected because it is more susceptible to the typical inversion-type twist of the ankle, but the distal tibia, fibula, and talus bone must also be evaluated because they are the critical parts of the ankle joint (Singh et al.,2018).

I will visually evaluate and palpate the bilateral lower limbs for any deformities, as well as examine the distal neurovascular state of pulse, motor, and sensory, highlighting any distinctive flexion limits or pain exacerbations. I will do the Talar Tilt Test to examine a lateral ankle sprain, the external rotation test to measure medial ligament injury, Thompson’s test to examine the heel cord, and the compression test to evaluate the distal tibiofibular joint.

I would be using the Ottawa ankle rule as a reference for radiologic diagnoses based on physical examination, and seek an x-ray if the client complains of pain in the malleolar zone, as well as pinpoint discomfort either to the lateral or medial malleolus, or incapacity to maneuver (Yilmaz et al.,2021).

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