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COLLEAGUE 2 RESPONSE
S:
CC: I was playing soccer over the weekend and heard a “pop.” Right Ankle Pain
HPI: A 46-year-old woman who has complained of pain in both ankles but is concerned about the right ankle. Patient is able to bear weight but reports being uncomfortable. Patient has not had any leg or lower extremity pain before today.
PMH: Soft tissue injuries before as a teenager with both ankles sprained, no past surgery, last period 14 day ago
FH: Mother has Diabetes and HTN Age 75, Father passed from Colon Cancer at the age of 65 Y/O
SH: Diet with vegetables and salads mainly with very little protein, exercise daily (jogging), no history of smoking
O: 46 Y/O Woman unable to bear much weight on the right ankle, 5/0 pain in the right ankle
VS: 139/82 HR: 98 T: 98.6 R: 18 Wt: 123 Ht: 5”4
General: Negative for fever chills, Patient grimacing in pain
Cardiovascular: Patient HR elevated
Gastrointestinal: Abdominal sounds hard in all 4 quadrants, Patient has no massess or brusing present
Pulmonary: Patient has no SOB, lungs are CTA
Musco skeletal: Swelling of the right ankle and ecchymosis. Palpate heat, tenderness, swelling or resistance to movement in the right ankle. Palpated for crepitus (break) no crepitus felt. Ottawa ankle rules must be applied and the tenderness 6 cm distal to the posterior edge of the tibia. Patient unable to bear weight comfortability for at least four steps.
A: Differential Diagnosis :
Primary Diagnsosis Ankle Fracture: Bone tenderness along the distal of the posterior edge of the tibia 6 cm. Patient reported playing soccer over the weekend and hear a “pop”. Ankle fractures can be caused by various modes of trauma, e.g., twisting, impact, and crush injuries (Wire et al., 2011). Drawer test performed and instability shown. Pain at the site means a fracture or at least the need to obtain imaging series, Ankle X-Ray.
Stress Fracture: In contrast to acute fractures, which typically occur with a single maximal load, stress fractures occur due to repetitive, submaximal loading of a bone, leading to microfractures that are unable to heal due to bone resorption and bone formation imbalances. On physical examination, pain with weightbearing or range of motion of a joint near a stress fracture may be elicited, point tenderness is almost universal, and in more superficial areas, edema, warmth, ecchymosis, or even a palpable callus may be present (Mayer et al., 2014).
Medial Ankle Sprain: The deltoid ligament complex (DLC) is the primary medial ligamentous stabilizer of the ankle. In athletic settings, this injury typically occurs as a result of contact with another player. Collegiate men’s and women’s soccer, men’s football, and women’s gymnastics have the highest incidence of medial ankle sprain (Chen et al., 2019).
Torn Achiles: Achilles’s tendon rupture is the most common tendon rupture in the lower extremity. The injury most commonly occurs in adults in their third to fifth decade of life. Acute ruptures often present with sudden onset of pain associated with a “snapping” or audible “pop” heard at the site of injury. On physical exam, patients with Achilles’s tendon rupture are unable to stand on their toes or have very weak plantar flexion of the ankle (Shamock & Varcallo, 2021). Thompson Test performed to determine tendon ruptures.
Calcaneus Fracture: The hindfoot articulates with the tibia and fibula creating the ankle joint. The subtalar or calcaneal joint accounts for at least some foot and ankle dorsal/plantar flexion. Calcaneal fractures most commonly occur during high energy events leading to axial loading of the bone but can occur with any injury to the foot and ankle. Patients will present with diffuse pain, edema, and ecchymosis at the affected fracture site (Davis et al., 2021). The patient is not likely able to bear weight. Bohler’s Angle may be depressed on plain radiographs.