Use the Episodic/Focused SOAP Template and create an episodic/focused note about the patient in the case study 1 & 2 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.
Below is the case study 1 to be used Case Study 1 : Acute Ankle Injury in a 46-Year-Old Female Soccer Player
A 46-year-old female soccer player presented to the clinic with complaints of severe pain in both ankles, with the right ankle being more concerning. The patient reported that the symptoms began over the weekend during a soccer game when she suddenly heard a ‘pop’ sound. She described the pain as intense, rating it as eight out of 10 on a pain scale. The pain worsened with movement and was slightly relieved by taking Ibuprofen. Although she could bear weight on both limbs, she experienced discomfort while doing so.
Upon further inquiry, the patient denied any history of similar injuries in the past. She reported no previous hospitalizations or surgeries, and her medical history was unremarkable, with no history of chronic conditions such as hypertension, diabetes, or asthma. The patient was not currently on any medications other than Ibuprofen for pain relief, and she had no known allergies to food, drugs, or environmental factors.
During the physical examination, the patient appeared well-nourished and in no acute distress. Her vital signs were within normal limits. In the musculoskeletal examination, the patient exhibited pain in both ankles, with the right ankle being more affected. There were no visible signs of joint swelling or deformities, and she had no limitations in other joints. Case Study 2: Bilateral Knee Pain in a 15-Year-Old Male Baseball Player
Jake Smith, a 15-year-old Caucasian male, presented to the clinic with complaints of bilateral knee pain accompanied by a clicking and catching sensation. He reported that the pain began approximately two weeks ago and described it as a dull ache located in the posterior aspect of both knees. Additionally, he felt pressure behind both knees. Jake attributed the onset of pain to his participation in baseball practice. Activities such as exercise, running in gym class, and sports exacerbated the pain, while rest and ibuprofen provided relief. He rated his pain as 4 out of 10 during the current visit, but noted that it typically increased to 7 out of 10 after baseball practice and gym class.
Jake’s medical history was unremarkable, with no previous surgeries or significant childhood diseases reported. He regularly took Olly Kids Multivitamin + Probiotic as a supplement for immune support and consumed Ibuprofen as needed for pain relief. There were no known allergies to medications, food, latex, or environmental factors.
In terms of social history, Jake lived with his parents, younger brother, and younger sister. He attended Cardinal High School and enjoyed playing baseball in the spring, with plans to participate in football during the fall season. His mother worked as a second-grade schoolteacher, while his father worked as an engineer at a local factory. Jake had access to healthcare providers and maintained a healthy diet. He denied tobacco, alcohol, and illicit drug use, although he mentioned that some of his friends had recently started vaping. Jake denied engaging in sexual activity.
The family history revealed his maternal grandmother had a history of hypertension and breast cancer, resulting in a bilateral mastectomy in 2018. His maternal grandfather had hypertension and high cholesterol levels. On his paternal side, his grandmother had type 2 diabetes, hypertension, and high cholesterol levels. There were no significant medical conditions reported for his paternal grandfather. Jake’s younger brother had asthma, while his younger sister had no significant medical history.
