Posted: December 25th, 2022
Advanced Health Assessment and Diagnostic Essay Discussion Paper
Ankle Pain Response
Thank you for your very insightful note. The specific techniques in your post, anterior drawer test and inversion stress test (lift ankle forward), are both great proposals. There are different tests that might be employed in diagnosing ankle discomfort. For the aim of this discussion, we will address the first ankle examination and the Kleiger’s (external rotation) test, which is helpful in assisting with diagnosing the etiology responsible for ankle discomfort. According to Laskowski et al (2020) the ankle examination is divided into three simple steps Advanced Health Assessment and Diagnostic Essay Discussion Paper.
The Kleiger’s test is described in detail in Seidel’s handbook to physical examination (2017). To perform this test, the patient is asked to sit with his or her legs over the edge of the table, while the assessor stabilizes the lower leg with one hand and holds the medial element of the foot with the other hand, while keeping the ankle supported in neutral position and rotating the foot laterally (Ball et al., 2017). A positive result indicates a strain of the deltoid ligament (resulting in medial/lateral joint discomfort).
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2017). Seidel’s Guide to Physical Examination-E-Book: An Interprofessional Approach. Elsevier Health Sciences.
Laskowski, E. R., Johnson, S. E., Shelerud, R. A., Lee, J. A., Rabatin, A. E., Driscoll, S. W., … & Terzic, C. M. (2020, August). The telemedicine musculoskeletal examination. In Mayo Clinic Proceedings (Vol. 95, No. 8, pp. 1715-1731). Elsevier Advanced Health Assessment and Diagnostic Essay Discussion Paper
INITIAL ASSIGNMENT WE WERE ASSIGNED AND WHAT THE RESPONSE IS REGARDING 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. Rubric for 1st Response 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 Advanced Health Assessment and Diagnostic Essay Discussion Paper.
Communication is professional and respectful to colleagues. Responses to faculty questions are fully answered, if posed. Response is effectively written in standard, edited English. COLLEAGUE # 1 TO RESPOND TO IN THIS RESPONSE POST Review Case Study #1 Ankle Pain Episodic/Focused SOAP Note S. CC: Pain in both of her ankle, heard a “pop”. HPI: The patient is a 46 year old Hispanic female, was playing soccer over the weekend when she heard a “pop”, and now is complaining of bilateral ankle pain. Patient states she is more concerned for her right ankle. States pain is 4/10 while resting, and 8/10 when she attempts to walk. Pain does not radiate anywhere. PMH: Hypertension Medications: Lisinopril 5mg once daily Allergies: NKDA, no seasonal allergies, animals or latex FH: Mother has HTN, and Cholesterol; Father at 75 of CVA. No history of premature cardiovascular disease in first degree relatives. SH : Denies use of tobacco, alcohol or any drugs. Married for 7 years, 2 children. Patient works in a bank. Tries to maintain a healthy life, plays soccer 4 times a week, and eats healthy. ROS General–Negative for fevers, chills, fatigue Cardiovascular–Negative for orthopnea, No edema, Denies Chest pain Gastrointestinal–Denies nausea, vomiting, diarrhea, and abdominal pain Pulmonary—Denies any shortness of breath, cough, or hemoptysis. O. VS: BP 135/65; P 75; R 18; T 97.8; 02 99% Wt 137 lbs; Ht 65” General–Pt appears calm, and cooperative. No acute distress noted. Dressed appropriate for the occasion. Gait is steady, but patient is limping due to right ankle pain. Cardiovascular—No JVD. Heart is regular. No murmurs, or gallops. No swelling. No cyanosis or clubbing. No bruits Gastrointestinal–The abdomen is symmetrical without distention, bowel sounds are normal in quality and intensity in all areas, No bruits or masses. No tenderness on palpation. Pulmonary– Lungs are clear to auscultation and percussion bilaterally Musculoskeletal: Full ROM to all extremities, but reports pain to bilateral ankles, more so to the right ankle. Brachial and radial pulses +2. Pedal pulses intact +2, no obvious deformities noted. Minor swelling noted to right ankle. Cap refill <2 secs. Skin warm to touch. Sensation intact. Diagnostic results: X-Ray: Plain X-rays of the ankle should be taken if there is pain in the malleolar zone and any one of the following: i) bone tenderness along the distal 6 cm of the posterior edge of the tibia or tip of the lateral malleolus; ii) bone tenderness along the distal 6 cm of the posterior edge of fibula or tip of the lateral malleolus; iii) inability to bear weight both immediately and in the emergency department for four steps (Polzer 2012). MRI: Magnetic resonance imaging (MRI) is increasingly being utilized in assessing patients with residual symptoms after initial conservative treatment because of its superior soft-tissue resolution and good correlation with objective arthroscopic findings (Tan 2016). Rheumatoid Factor & anti-CCP Differential Diagnosis: 1) Sprain : Ankle sprain contributes to 20–40% of sport injuries. Depending on the mechanism of injuries, particular group of ligaments are injured. 2) Tendonitis: Tendonitis is a common diagnosis in sports medicine Advanced Health Assessment and Diagnostic Essay Discussion Paper.
The traditional view of tendonitis is a tendon injury resulting from repetitive mechanical load with a subsequent inflammatory response. 3) Stress Fracture: Six to eight weeks after a sudden and non-gradual increase in the intensity of an athlete’s or new patient’s physical activity, this cyclical and repetitive physiological overloading may lead to the appearance of microfractures and may not allow the bone tissue to have sufficient time to undergo remodeling and adapt to the new condition, and thus to repair the microlesion (Astur 2015). 4) Anterior Ankle Impingement: An ankle impingement syndrome is characterized by a limited range of motion and pain when performing specific movements about the joint and often in a load-bearing position (Berman 2017). 5)Rheumatoid Arthritis: Foot and ankle joint disorders are serious issues for patients with rheumatoid arthritis (RA). More than 90% of patients with RA report foot symptoms at some time during the course of their disease ( Yano 2018). P. This section is not required for the assignments in this course (NURS 6512) but will be required for future courses. For this scenario, because the patient is presenting with pain around the malleolar area of the ankle, I would use the Ottawa Ankle rules to order an X-ray of the ankle. Also, the patient reports she can bear weight, but she is in pain. The Ottawa ankle rules showed high reliability for deciding when to take radiographs in foot and/or ankle sprains. Weight-bearing inability was the most important isolated item to predict fracture presence (Pires 2014). Aside from using the Ottawa rules, a full neurovascular assessment is done to assess the extent of the injury. Also, passive, and active ROM is also assessed. This examination will set a baseline for the providers and will be able to assess if any improvement is achieved. Reference: Astur, D. C., Zanatta, F., Arliani, G. G., Moraes, E. R., Pochini, A., & Ejnisman, B. (2015). Stress fractures: definition, diagnosis and treatment. Revista brasileira de ortopedia, 51(1), 3–10. https://doi.org/10.1016/j.rboe.2015.12.008 ALMEKINDERS, LOUIS C.; TEMPLE, JOHN D. Etiology, diagnosis, and treatment of tendonitis: an analysis of the literature, Medicine& Science in Sports & Exercise: August 1998 – Volume 30 – Issue 8 – p 1183-1190 Berman, Z., Tafur, M., Ahmed, S. S., Huang, B. K., & Chang, E. Y. (2017). Ankle impingement syndromes: an imaging review. The British journal of radiology, 90(1070), 20160735. https://doi.org/10.1259/bjr.20160735 Pires, R., Pereira, A., Abreu-E-Silva, G., Labronici, P., Figueiredo, L., Godoy-Santos, A., & Kfuri, M. (2014). Ottawa ankle rules and subjective surgeon perception to evaluate radiograph necessity following foot and ankle sprain. Annals of medical and health sciences research, 4(3), 432–435. https://doi.org/10.4103/2141-9248.133473 Polzer, H., Kanz, K. G., Prall, W. C., Haasters, F., Ockert, B., Mutschler, W., & Grote, S. (2012). Diagnosis and treatment of acute ankle injuries: development of an evidence-based algorithm. Orthopedic reviews, 4(1), e5. https://doi.org/10.4081/or.2012.e5 Tan, D. W., Teh, D., & Chee, Y. H. (2016)Advanced Health Assessment and Diagnostic Essay Discussion Paper.
Accuracy of magnetic resonance imaging in diagnosing lateral ankle ligament injuries: A comparative study with surgical findings and timings of scans. Asia-Pacific journal of sports medicine, arthroscopy, rehabilitation, and technology, 7, 15–20. https://doi.org/10.1016/j.asmart.2016.09.003 Yano, K., Ikari, K., Inoue, E., Sakuma, Y., Mochizuki, T., Koenuma, N., Tobimatsu, H., Tanaka, E., Taniguchi, A., Okazaki, K., & Yamanaka, H. (2018). Features of patients with rheumatoid arthritis whose debut joint is a foot or ankle joint: A 5,479-case study from the IORRA cohort. PloS one, 13(9), e0202427. https://doi.org/10.1371/journal.pone.0202427 Advanced Health Assessment and Diagnostic Essay Discussion Paper
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