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.

SW, 46, F, Caucasian

S.

CC: Bilateral ankle pain

HPI: SW, 46-year-old Caucasian female presents with bilateral ankle pain that started three days ago. Pt states that her right ankle is more of a concern than her left. States she was playing soccer over the weekend when she heard a “pop.” Claims she was running to kick the soccer ball when she slipped on the grass and fell on top of her right foot. She thinks she “rolled” her foot inward. States she is able to bear weight on both ankles, but the right is uncomfortable. Rates pain 7/10 in intensity for her right ankle, and 3/10 in intensity for her left ankle. She has been taking OTC 600mg ibuprofen every 8 hours for two days and has minor relief. States her right ankle pain is a 4/10 pain with ibuprofen, but only lasts a few hours. Confirms icing both ankles three times a day for the past three days. States walking, and standing is uncomfortable, and most movement makes the pain worse.

Current Medications: OTC 600mg Ibuprofen q 8 hours PRN pain

Allergies: NKA

PMHx: No chronic conditions; UTD on immunizations, last TdAp 2011, last influenza vaccine 10/2020.

Soc Hx: Lives at home with her husband, 11-year-old daughter, 13-year-old son, and 16-year-old son; works as stay at home for the past 16 years; lives in a multi-family home neighborhood with several friends in the neighborhood; negative tobacco use; consumes moderate alcohol, estimates 2-3 glasses of wine per week; exercises 4 days a week and plays soccer over the weekends with her 16-year-old to help him practice; denies cell phone use while driving; not currently on birth control and LMP was 2 /12 weeks ago; practices safe sex

Fam Hx: both parents still living; mother, 68-years-old, has history of hyperlipidemia; father, 70-years-old, has a history of HTN, hyperlipidemia, and CHF; paternal grandfather died at age 80 of pancreatic cancer; paternal grandmother died at age 83 of pneumonia; maternal grandfather, 89-years-old, has a history of COPD, HTN, and CHF; maternal grandmother, 86-years-old, has a history of kidney disease; 11-year-old daughter has a history of asthma; 13-year-old son has a history of anxiety, 16-year-old son is healthy; husband, 49-years-old suffers from HTN.

ROS:

GENERAL:  Right ankle pain, 7/10 pain; no weight loss, fever, chills, weakness or fatigue.

HEENT:  

• HEAD: denies headaches, dizziness, head injuries, or past head injuries
• EYES: wears corrective lenses for about 20 years; denies any vision changes
• EARS: denies any changes in hearing; no history of injuries; denies hearing aid use
• NOSE: denies any changes in sense of smell; denies nasal discharge or swelling
• THROAT: denies mouth sores or lesions; denies sore throat, dysphagia, or any injuries or surgeries to throat

SKIN: denies contact dermatitis or any other skin conditions; confirms bruising of right ankle

CARDIOVASCULAR:  denies chest pain, chest pressure or chest discomfort; denies palpitations or edema

RESPIRATORY:  denies shortness of breath, cough, or wheeze

GASTROINTESTINAL:  denies anorexia, nausea, vomiting or diarrhea; denies abdominal pain

NEUROLOGICAL: denies headaches, head injuries, dizziness, seizures, tremors, difficulty swallowing or speaking; denies gait disturbances

MUSCULOSKELETAL:  confirms right ankle pain near the right lateral malleolus; tenderness and swelling noted on right ankle; denies joint pain, stiffness, swelling, redness, or heat in upper extremities and left lower extremity; denies arthritis, hip dysplasia or scoliosis

O.

VITALS: BP 126/72 SpO2 99% T 98.7F HR 86 RR 18 W 148 Ht 5’7”

GENERAL:  No acute distress; AAO x3; patient sitting comfortably in patient chair

HEENT:  

• HEAD: normocephalic; no visible abnormal findings
• EYES: no visual loss, double vision, or yellow sclera; conjunctiva moist and pink; PERRLA
• EARS: no muffled hearing; no discharge
• NOSE: nasal mucosa pink; nares patent
• THROAT: oral mucosa moist and pink

SKIN: no freckles, birthmarks, or other discoloration of upper extremities; dark purple bruising of right ankle noted; no discoloration of lower left extremities; CRT <3 s of all extremities; no tenting of skin

CARDIOVASCULAR:  S1 and S2 audible heart sounds; no gallops, murmurs, or thrills; no edema

RESPIRATORY:  no adventitious breath sounds in all lung quadrants

GASTROINTESTINAL:  abdomen symmetric, rounded, no visible abnormal findings; no abdominal tenderness; no masses; normoactive bowel sounds in all quadrants

NEUROLOGICAL: steady, narrow-based gait; Romberg negative; 2+ reflexes in upper extremities and lower extremities; CN II-XII grossly intact; no focal neurological deficits

MUSCULOSKELETAL:  + right ankle pain near the right lateral malleolus; + tenderness and swelling noted on right ankle; denies joint pain, stiffness, swelling, redness, or heat in upper extremities and left lower extremity; denies arthritis, hip dysplasia or scoliosis; 5/5 muscle strength in upper and lower left extremities; 2/5 muscle strength in lower right extremity; decreased ROM of right ankle, 5 degrees eversion of right foot, 10 degrees inversion of right foot, 5 degrees dorsiflexion of right foot, 20 degrees plantar flexion of right foot; decreased Rom of left foot, 20 degrees inversion, 10 degrees eversion, 20 degrees dorsiflexion, 45 degrees plantar flexion; Full ROM of upper extremities; + Ottawa ankle rules (OAR): bone tenderness at posterior edge of lateral and medial malleolus; decreased ability to bear weight on right extremity

Diagnostic results:

• X-Ray of the bilateral ankles and bilateral lower leg: The X-Ray will help us determine if SW fractured her right lateral malleolus. X-Rays give us a good view of bone structure and can help rule out fracture, break, or strain. OAR is always to be performed before ordering imaging. Curr & Zyrichis (2015) state that providers are to perform an ankle X-ray if the patient is unable to bear weight, 4 steps immediately after injury and in ED, and has bone tenderness at the posterior edge or tip of malleolus. If a patient does not present with both characteristics, they are OAR -. Without bone pain, which is determined using OAR, an X-ray is not indicated. SW had + OAR: bone tenderness at posterior edge of lateral and medial malleolus and decreased ability to bear weight on her right ankle. She had swelling, tenderness, and bruising near the right lateral malleolus.
• MRI: An MRI is used to get a more detailed look at tissues, ligaments, and organs in the body. Unlike an X-Ray, which can only look at bones, the MRI will help us determine any ligament strain or tears that SW may have had. SW states that she heard a “pop” while she was playing soccer. Most of the time, the popping of the ankle is the sound of the ligament tearing. A crack sound may indicate a fracture or break, and a popping sound usually indicates an ankle sprain. “You hear the popping sound of your ligaments tearing completely, and you can’t put weight on your ankle” (“Common Injuries, 2019). Those characteristics signify an ankle sprain. Knowing that SW heard a “pop” sound when she injured her ankle, leads us to believe a ligament was involved. Therefore, an MRI is an appropriate diagnostic in this scenario.
• Stress-View Radiography: When an X-Ray doesn’t give a clear enough view of a fracture or break, a stress-view radiography can be used to help determine between an ankle sprain or an injury that may require casting. “because a deltoid injury is not seen on plain radiographs, an unstable injury can appear to be a stable one on a standard mortise view. The quick and easy way to differentiate these two are via stress view of the ankle” (Guiney, 2016).

A.

Differential Diagnoses:

• Right Ankle Sprain/Soft-Tissue Injury: An ankle sprain is typically caused by an inversion or eversion of the ankle during strenuous activity, a fall, exercise, or sports activities. SW was playing soccer when she slipped on the grass and rolled on her ankle, which she the heard a “popping sound.” The popping sound indicates a ligament tear or strain, which results in an ankle sprain. “In soccer players, playing on natural grass as opposed to artificial turf increases risk for lateral ankle sprain” (Chen, McInnis, & Borg-Stein, 2019). She had positive right ankle pain near the lateral malleolus, as well as tenderness, swelling, and bruising. Her muscle strength of her right ankle was 2/5 compared to 5/5 for her left ankle. She had decreased ROM of her right ankle and positive OAR. All findings point to an ankle sprain. With proper radiography and an MRI, we will be able to diagnose a soft-tissue injury.
• Peroneal Tendon Tear: “Pain with resisted eversion and tenderness to palpation are common with peroneal tendon tears. Passive inversion of the hindfoot may provoke pain as well. Subluxation of the peroneal tendons over the posterior border of the fibular may be demonstrated on physical examination” (Danna & Brodsky, 2020). SW had positive findings of swelling/subluxation near the right lateral malleolus, located at the peroneal tendons. ROM was decreased with 10 degrees inversion and 5 degrees eversion of the right foot. SW also heard a “popping sound” at the time of injury, indicating a possible tendon tear, rupture, or sprain of her ankle. An MRI would help determine this diagnosis.
• Ankle Tendonitis: Tendonitis occurs when a tendon is inflamed and typically presents with a patient unable to bear weight, swelling, pain, and pain with palpation. ROM is usually decreased as well.  It occurs when the ankle is manipulated, usually continuously for a period of time, but can also occur with an injury. SW had + OAR (bone tenderness), swelling, tenderness, unable to bear weight, and decreased ROM. Considering SW plays soccer very regularly with her older son, it is possible that with repetitive overuse of her ankles and feet could have caused tendinitis. It is also important to wear appropriate shoes during exercise. Without appropriate support of her shoes, tendinitis can occur. It is possible SW is suffering from tendonitis considering her symptoms. An MRI would help determine this diagnosis.
• Right Ankle Fracture: With ankle fractures, individuals can hear a “crack” sound. Seeing as SW heard a “pop,” it is not likely she suffered a fracture. With fractures, pain is usually relieved with rest and an individual is not able to put any weight on the injury. SW is able to bear weight, but has discomfort doing so. Therefore, again, she most likely did not suffer a fracture. This can be confirmed with an X-Ray.
• Syndesmotic Injury:  These injuries are also known as high ankle sprains and they require a lot of force to injure this specific ligament. SW fell and rolled on her ankle, which would not cause a lot of force on her ankle. The syndesmotic ligaments hold the distal tibia and fibula together. They occur when an ankle is externally rotated during injury affecting the interosseous membrane. These injuries typically occur in sports such as hockey and skiing, where injuries cause a lot more force. Her injury was low ankle sprain which occurs when an ankle is everted. Low ankle sprains occur in sports such as soccer and basketball, which SW was playing soccer. Therefore, she most likely did not suffer a syndesmotic injury.  

References

Chen, E., McInnis, K., & Borg-Stein, J. (2019). Ankle sprains: evaluation, rehabilitation, and prevention. Current Sports Medicine Reports: June 2019. 18(6), 217-233. https:/doi.org/10.1249/JSR.0000000000000603

Common Injuries. (2019). Backpacker, 47(2), 47. https://link.gale.com/apps/doc/A575011128/EAIM?u=minn4020&sid=EAIM&xid=13250273

Curr, S., & Xyrichis, A. (2015). Does nurse-led initiation of Ottawa ankle rules reduce ED length of stay? International Emergency Nursing. 23(4), 3147-322. https://doi.org/10.1016/j.ienj.2015.01.006

Danna, N., & Brodsky, J. (2020). Diagnosis and Operative Treatment of Peroneal Tendon Tears. Sage Journals. https://doi.org/10.1177/2473011420910407

Guiney, A. (2016). Ankle Stress Views: Why, When + What. CoreEm. Retrieved from https://coreem.net/core/ankle-stress-views/#references