NURS 6512 Episodic/Focused SOAP Note Template

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NURS 6512 Episodic/Focused SOAP Note Template

NURS 6512 Episodic/Focused SOAP Note Template

Patient Information:
F.P., age 46, Caucasian female
Subjective:
CC: Pain to both ankles, but more concerned about the right ankle
HPI: F.P. is a 46-year-old Caucasian female that presents with bilateral ankle pain. She is more concerned about the right ankle as she heard a “pop” while she was playing soccer over the weekend. She can uncomfortably bear weight to the right ankle. Patient describes the pain as achy and throbbing at times, over the lateral aspect of the right ankle. She currently rates the pain as a 4/10 at rest, and a 7/10 with ambulation. She did elevate and ice the right ankle after the injury. She has taken ibuprofen intermittently for pain relief with moderate results. The pain occasionally radiates approximately 4 inches up the lateral aspect of the right lower extremity. There was immediate swelling to the right ankle after the pop. Her left ankle bothers her at times, with an intermittent pain score of 3-4/10; however, there is no acute change to the left ankle at this time.
Current Medications:
1) Birth control pills
2) Effexor 37.5 mg p.o. daily for depression
3) OTC ibuprofen 600 mg p.o. Q6H prn, pain
Allergies: Denies allergies to drugs, food and latex. Denies environmental allergies.
PMHx: She receives a flu vaccine annually. She has been vaccinated for COVID-19. She received all childhood immunizations appropriately and was last vaccinated with a tetanus booster in 2017.
1) Depression, well-controlled on Effexor
2) C-section x 1
Soc Hx: Patient is married and has one child, age 13. She is a cashier at a local nursery. She was an athletic as a child. She does not smoke, drink, or use recreational drugs. She maintains her health playing soccer with friends and lifting weights 3 x a week. She drinks one cup of coffee daily. Her diet is plant-based. She has been a vegetarian for 10 years.
Fam Hx: Mother is 79, alive and well, with history of severe rheumatoid arthritis, depression, HTN. Father is 82, alive and well, with history of prostate cancer (in remission), mental health disorders (unspecified), HTN, HLD. She has one brother who is 53, alive and well, with “undiagnosed mental health disorders” but it otherwise healthy. Her son, age 13, is healthy. Health history of deceased grandparents include arthritis, colon cancer, prostate cancer, HTN, cirrhosis r/t alcoholism, HLD.
ROS:
GENERAL: Denies weight loss, fever, chills, weakness or fatigue.
HEENT: Denies headaches, changes to vision, hearing, taste, or smell.
SKIN: Denies rash or itching, easy bruising, or poor wound healing.
CARDIOVASCULAR: Denies chest pain, chest pressure or chest discomfort. No palpitations or edema. Denies paroxysmal nocturnal dyspnea and orthopnea. Denies exercise intolerance.
PERIPHERAL VASCULATURE: Denies easy bruising, pain to calves, blood clots, or history of aneurysms.
MUSCULOSKELETAL: Endorses bilateral ankle pain, right greater than left, with swelling to right lateral ankle and difficulty bearing weight. She denies prior joint stiffness, bony deformities, decreased range of motion to bilateral ankles or any other joints.
NEUROLOGIC: Denies history of CVA or TIA, headaches, dizziness, concussion, seizures, weakness, vertigo, numbness and tremors.
MENTAL HEALTH: Reports history of depression which is well-controlled. She reports stable mood. Denies sleep disturbances, irritability, difficulty concentrating, and mood swings.

Objective:
Physical exam:
Vital signs: BP 128/64, HR 70, RR 17, temp 97.9˚F, pulse ox 99% on room air. Height: 5’5”, weight: 123. BMI: 20.5
General: well-developed, well-nourished 46-year-old Caucasian female in mild discomfort related to right ankle pain. She is pleasant and cooperative.
HEENT: Head is normocephalic and atraumatic. PERRLA, EOMI. Sclera anicteric.
Skin: Warm and dry. No noted rashes, wounds, lesions, or excess bruising. There is bruising to right lateral ankle.
Neck: Supple. Full range of motion.
Chest: lungs clear to auscultation. No cough or dyspnea. Heart regular, S1, S2 appreciated without murmurs, rubs, or gallops. No edema noted aside from right lateral ankle.
Peripheral vasculature: Bilateral dorsalis pedis pulses +2, Bilateral posterior tibial pulses +2, bilateral popliteal pulses +2, bilateral femoral pulses +2.
Musculoskeletal System: Right lateral ankle swollen, with decreased range of motion, weakness, and tenderness with palpation to lower aspect of fibula and surrounding ligaments (anterior and posterior tibiofibular ligaments, posterior and anterior talofibular ligaments, and calcaneofibular ligament) as well as lateral malleolus. There is generalized bruising to the lateral aspect of the right ankle. Medial aspect of right ankle non-tender, without bony deformities or bruising. Left ankle without swelling, bruising, overt tenderness with palpation. No noted deformities or decreased range of motion to joints of toes, knees, hands, or fingers. Spine is straight. Patient is able to bear weight on the right foot, with pain. Gait is disturbed due to pain.
Diagnostic results: Right ankle radiograph, if indicated by Ottawa ankle rules; Ankle ultrasound, if indicated; Stress tests to bilateral ankles, if indicated.

Assessment:
Differential Diagnoses:
1) Right ankle inversion sprain
2) Peroneal tendon disorders
3) Chronic ankle instability
4) Ehlers-Danlos syndrome
5) Avulsion fracture of right ankle

Introduction
Ankle injuries constitute a large portion of healthcare visits orthopedic providers, emergency rooms, and urgent care centers. The ankle is highly susceptible to acute injury given its range of motion, high quantity of bones, ligaments, and tendons, and the fact that the ankles bear the weight of the entire body. The structures that could be involved in lateral ankle pain include the anterior and posterior tibiofibular ligaments, anterior and posterior talofibular ligaments, and calcaneofibular ligament, as well as the peroneus longus and peroneus brevis muscles and their tendons, the lateral malleolus, calcaneus, talus, and fibula bones. Damage to these structures from acute muscle strains, ligamental sprains, or fractures, as well as some chronic disorders will be discussed.
Right Ankle Inversion Sprain
Ankle sprains occur with activity. They range from mild to severe and result from inversion or eversion of the foot. According to Ireland (2017), 19.4% of women’s soccer game injuries are related to the ankle. Our patient was playing soccer when she heard a pop that was followed by pain and difficulty walking. Using the Ottawa Ankle Rules, we can determine if a radiograph is warranted. The Ottawa Ankle Rules were created to eliminate unnecessary ankle radiographs by identifying criteria that could rule out a fracture of the foot or ankle without x-ray (Bachmann et al., 2003). The assessment includes determining if the patient can walk 4 steps immediately after injury, or at the emergency department, and bony tenderness over lateral and medial malleolus, 5th metatarsal, and navicular bones; an ankle x-ray is indicated if the patient cannot bear weight, or there is any bony tenderness (Bachmann et al., 2003). Based on these criteria, and the fact that our patient can walk, albeit painfully, it would not be indicated to assess her ankle via ankle radiograph. Ankle sprains are associated with pain and swelling which this patient endorses. The fact that this patient complains of bilateral ankle pain leads one to consider an acute injury to the right and an underlying disorder of both ankles. This will be discussed further.

Peroneal Tendon Disorders
Due to the patient’s complaints of bilateral ankle pain, other disorders should be considered as an underlying cause. According to Davda et al. (2017), it is often difficult to distinguish a lateral ankle sprain from abnormalities of the peroneal tendons. These tendons run just inferior to the lateral malleolus and along the side of the foot. They attach the tendons of the peroneus longus and peroneus brevis muscles to bones in the lateral aspect of the mid-foot. They function to stabilize the lateral foot and evert the foot (Davda et al., 2017). This group of disorders include tendonitis/tenosynovitis, subluxation and/or dislocation of the tendon, or tendonous tears or splits (Davda et al., 2017). Examination of the ankle and foot should include assessing the lateral ankle ligaments listed above, as well as assessing foot type and palpating the peronei, in conjunction with radiography, MRI and ultrasound to confirm diagnosis (Davda et al., 2017).
Chronic Ankle Instability
Another condition to be considered in this case is chronic ankle instability. If this patient has a history of multiple ankle sprains, her ankles may have become chronically unstable, predisposing her to acute inversion injuries. According to Radwan et al. (2016), a diagnosis can be made if the patient has symptoms of pain, swelling, clinical instability, injury and re-injury, to the lateral aspect of the ankle(s), for greater than 6 months. While this is very common in children and young adult athletes, it can also affect older adults’ quality of life. Arthroscopy, MRI, CT, radiographs, and ultrasounds can be used to diagnose this condition and grade the level of injury (Radwan et al., 2016).
Ehlers-Danlos Syndrome
Ehlers-Danlos syndrome (EDS) is a genetic disorder affecting the connective tissues. If this is suspected, it would be important to question the patient on any history of her family members having similar issues or those described below. There are several subtypes of EDS and thus presentation may be different among patients and difficult to isolate to the syndrome itself. Potential signs include tissue fragility (from easy bruising and impaired wound healing, to GI bleeds and CV events), generalized hypermobile joints (all four limbs and axial skeleton), and hyperextensible skin (excessive stretchiness to skin in three of four areas: distal forearms, neck, knees, dorsum of hands, elbows) (Miller & Grosel, 2020). Further assessment of our patients’ other limb joints and spine would be required as well as examination of skin elasticity. Genetic testing can confirm all subtypes except hEDS (Miller & Grosel, 2020). In addition to measuring the stretch of the skin in the above listed areas, a Beighton score may be calculated to identify generalized joint hypermobility, but there are no other identifying clinical tests to confirm diagnosis (Miller & Grosel, 2020).
Avulsion Fracture
A final differential diagnosis that could be applied to the painful right ankle is an avulsion fracture. This occurs at the sight where a tendon attaches to bone, causing a bone fragment to tear away. The bones that may be affected in the lateral ankle include the lateral malleolus, lateral border of the talus, and 5th metatarsal (Vannabouathong et al., 2018). This fracture can be diagnosed with radiography. The fact that our patient can walk on her injured right foot makes this the least likely diagnosis.
Conclusion
It is likely this patient has sprained her right ankle. Her reports of pain and difficulty walking after playing soccer, during which she heard her ankle pop, makes this the most likely diagnosis. Consideration needs to be taken to the fact that she complained of bilateral ankle pain. This could represent an underlying condition like arthritis, Ehlers-Danlos syndrome, or a peroneal tendon disorder. It is less likely she has an avulsion fracture of the right ankle due to the fact that she can bear weight on the foot.

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NURS 6512 Episodic/Focused SOAP Note Template

NURS 6512 Episodic/Focused SOAP Note Template

References
Bachmann, L., Kolb, E., Koller, E., Steurer, J., & ter Riet, G. (2003). Accuracy of Ottawa ankle rules to
exclude fractures of the ankle and mid-foot: systematic review. British Medical Journal, 326,
1-7. doi: https://doi.org/10.1136/bmj.326.7386.417
Davda, K., Malhotra, K., O’Donnell, P., Singh, D., & Cullen, N. (2017). Peroneal tendon
disorders. EFORT Open Reviews, 2(6), 281-292. doi: 10.1302/2058-5241.2.160047
Ireland, M.D., M. (2017, February 1-5). Ankle Injuries: Presentation, work-up, differential diagnosis, and
treatment [Conference session]. ACSM Team Physician Course-Part II: Essentials of sports
medicine: From sideline to the clinic, San Diego, CA, United States.
http://forms.acsm.org/tpc2017/PDFs/10%20Ireland.pdf
Miller, E. & Grosel, J. (2020). A review of Ehlers-Danlos syndrome. Journal of the American
Academy of Physician Assistants, 33(4), 23-28.
doi: 10.1097/01.JAA.0000657160.48246.91
Radwan, A., Bakowski, J., Dew. S., Greenwald, B., Hyde, E., & Webber, N. (2016).
Effectiveness of ultrasonography in diagnosing chronic lateral ankle instability: A
systematic review. International Journal of Sports Physical Therapy, 11(2), 164-174.
Vannabouathong, C., Ayeni, O., & Bhandari, M. (2018). A narrative review on avulsion
fractures of the upper and lower limbs. Clinical Medicine Insights: Arthritis and
Musculoskeletal Disorders, 11, 1-10. doi: 10.1177/1179544118809050

Case 2: Ankle Pain

Photo Credit: University of Virginia. (n.d.). Lateral view of ankle showing Boehler’s angle [Photograph]. Retrieved from http://www.med-ed.virginia.edu/courses/rad/ext/8ankle/01anatomy.html. Used with permission of University of Virginia.
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 Ottawa ankle rules to determine if you need additional testing?

Discussion: Assessing Musculoskeletal Pain

Photo Credit: Getty Images/Fotosearch RF
The body is constantly sending signals about its health. One of the most easily recognized signals is pain. Musculoskeletal conditions comprise one of the leading causes of severe long-term pain in patients. The musculoskeletal system is an elaborate system of interconnected levers that provides the body with support and mobility. Because of the interconnectedness of the musculoskeletal system, identifying the causes of pain can be challenging. Accurately interpreting the cause of musculoskeletal pain requires an assessment process informed by patient history and physical exams.
In this Discussion, you will consider case studies that describe abnormal findings in patients seen in a clinical setting.
To prepare:
• By Day 1 of this week, you will be assigned to one of the following specific case studies for this Discussion. Please see the “Course Announcements” section of the classroom for your assignment from your Instructor.
• Your Discussion post should be in the Episodic/Focused SOAP Note format rather than the traditional narrative style Discussion posting format. Refer to Chapter 2 of the Sullivan text and the Episodic/Focused SOAP Template in the Week 5 Learning Resources for guidance. Remember that all Episodic/Focused SOAP notes have specific data included in every patient case.
• Review the following case studies:
Case 1: Back Pain

Photo Credit: University of Virginia. (n.d.). Lumbar Spine Anatomy [Photograph]. Retrieved from http://www.med-ed.virginia.edu/courses/rad/ext/5lumbar/01anatomy.html. Used with permission of University of Virginia.
A 42-year-old male reports pain in his lower back for the past month. The pain sometimes radiates to his left leg. In determining the cause of the back pain, based on your knowledge of anatomy, what nerve roots might be involved? How would you test for each of them? What other symptoms need to be explored? What are your differential diagnoses for acute low back pain? Consider the possible origins using the Agency for Healthcare Research and Quality (AHRQ) guidelines as a framework. What physical examination will you perform? What special maneuvers will you perform?
Case 3: Knee Pain

Photo Credit: University of Virginia. (n.d.). Normal Knee Anatomy [Photograph]. Retrieved from http://www.med-ed.virginia.edu/courses/rad/ext/7knee/01anatomy.html. Used with permission of University of Virginia.
A 15-year-old male reports dull pain in both knees. Sometimes one or both knees click, and the patient describes a catching sensation under the patella. In determining the causes of the knee pain, what additional history do you need? What categories can you use to differentiate knee pain? What are your specific differential diagnoses for knee pain? What physical examination will you perform? What anatomic structures are you assessing as part of the physical examination? What special maneuvers will you perform?
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.
Note: Before you submit your initial post, replace the subject line (“Discussion – Week 8”) with “Review of Case Study ___.” Fill in the blank with the number of the case study you were assigned.
By Day 3 of Week 8
Post an episodic/focused note about the patient in the case study to which you were assigned using the episodic/focused note template provided in the Week 5 resources. Provide evidence from the literature to support diagnostic tests that would be appropriate for each case. List five different possible conditions for the patient’s differential diagnosis, and justify why you selected each.
Note: For this Discussion, you are required to complete your initial post before you will be able to view and respond to your colleagues’ postings. Begin by clicking on the “Post to Discussion Question” link, and then select “Create Thread” to complete your initial post. Remember, once you click on Submit, you cannot delete or edit your own posts, and you cannot post anonymously. Please check your post carefully before clicking on Submit!
Read a selection of your colleagues’ responses.
By Day 6 of Week 8
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.
Submission and Grading Information
Grading Criteria

To access your rubric:
Week 8 Discussion Rubric

Post by Day 3 of Week 8 and Respond by Day 6 of Week 8

To Participate in this Discussion:
Week 8 Discussion

Rubric Detail
Select Grid View or List View to change the rubric’s layout.
Content
Name: NURS_6512_Week_8_Discussion_Rubric
• Grid View
• List View
Excellent Good Fair Poor
Main Posting Points Range: 45 (45%) – 50 (50%)
“Answers all parts of the Discussion question(s) with reflective critical analysis and synthesis of knowledge gained from the course readings for the module and current credible sources. Supported by at least three current, credible sources. Written clearly and concisely with no grammatical or spelling errors and fully adheres to current APA manual writing rules and style. Points Range: 40 (40%) – 44 (44%)
“Responds to the Discussion question(s) and is reflective with critical analysis and synthesis of knowledge gained from the course readings for the module. At least 75% of post has exceptional depth and breadth. Supported by at least three credible sources. Written clearly and concisely with one or no grammatical or spelling errors and fully adheres to current APA manual writing rules and style. Points Range: 35 (35%) – 39 (39%)
“Responds to some of the Discussion question(s). One or two criteria are not addressed or are superficially addressed. Is somewhat lacking reflection and critical analysis and synthesis. Somewhat represents knowledge gained from the course readings for the module. Post is cited with two credible sources. Written somewhat concisely; may contain more than two spelling or grammatical errors. Contains some APA formatting errors. Points Range: 0 (0%) – 34 (34%)
“Does not respond to the Discussion question(s) adequately. Lacks depth or superficially addresses criteria. Lacks reflection and critical analysis and synthesis. Does not represent knowledge gained from the course readings for the module. Contains only one or no credible sources. Not written clearly or concisely. Contains more than two spelling or grammatical errors. Does not adhere to current APA manual writing rules and style.
Main Post: Timeliness Points Range: 10 (10%) – 10 (10%)
Posts main post by Day 3. Points Range: 0 (0%) – 0 (0%)
N/A Points Range: 0 (0%) – 0 (0%)
N/A Points Range: 0 (0%) – 0 (0%)
Does not post main post by Day 3.
First Response Points Range: 17 (17%) – 18 (18%)
“Response exhibits synthesis, critical thinking, and application to practice settings. Provides clear, concise opinions and ideas that are supported by at least two scholarly sources. Demonstrates synthesis and understanding of Learning Objectives. Communication is professional and respectful to colleagues. Responses to faculty questions are fully answered, if posed. Response is effectively written in standard, edited English. Points Range: 15 (15%) – 16 (16%)
“Response exhibits critical thinking and application to practice settings. Communication is professional and respectful to colleagues. Responses to faculty questions are answered, if posed. Provides clear, concise opinions and ideas that are supported by two or more credible sources. Response is effectively written in standard, edited English. Points Range: 13 (13%) – 14 (14%)
“Response is on topic and may have some depth. Responses posted in the Discussion may lack effective professional communication. Responses to faculty questions are somewhat answered, if posed. Response may lack clear, concise opinions and ideas, and a few or no credible sources are cited. Points Range: 0 (0%) – 12 (12%)
“Response may not be on topic and lacks depth. Responses posted in the Discussion lack effective professional communication. Responses to faculty questions are missing. No credible sources are cited.
Second Response Points Range: 16 (16%) – 17 (17%)
“Response exhibits synthesis, critical thinking, and application to practice settings. Provides clear, concise opinions and ideas that are supported by at least two scholarly sources. Demonstrates synthesis and understanding of Learning Objectives. Communication is professional and respectful to colleagues. Responses to faculty questions are fully answered, if posed. Response is effectively written in standard, edited English. Points Range: 14 (14%) – 15 (15%)
“Response exhibits critical thinking and application to practice settings. Communication is professional and respectful to colleagues. Responses to faculty questions are answered, if posed. Provides clear, concise opinions and ideas that are supported by two or more credible sources. Response is effectively written in standard, edited English. Points Range: 12 (12%) – 13 (13%)
“Response is on topic and may have some depth. Responses posted in the Discussion may lack effective professional communication. Responses to faculty questions are somewhat answered, if posed. Response may lack clear, concise opinions and ideas, and a few or no credible sources are cited. Points Range: 0 (0%) – 11 (11%)
“Response may not be on topic and lacks depth. Responses posted in the Discussion lack effective professional communication. Responses to faculty questions are missing. No credible sources are cited.
Participation Points Range: 5 (5%) – 5 (5%)
Meets requirements for participation by posting on three different days. Points Range: 0 (0%) – 0 (0%)
N/A Points Range: 0 (0%) – 0 (0%)
N/A Points Range: 0 (0%) – 0 (0%)
Does not meet requirements for participation by posting on three different days.
Total Points: 100
Name: NURS_6512_Week_8_Discussion_Rubric

 

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