SOAP note: Right Ankle Sprain Assignment

Patient information

Patient initial: G.H. Age: 10.       Sex: male      Race: Caucasian

CC: Right ankle sprain

HPI: G H, a 10-year-old Caucasian male, presented at the clinic with his grandmother, complaining of a three-week-old right ankle sprain. He reported injuring his foot while playing football with his classmates six weeks ago, and the pain, which he scored 6/10, lingered despite his frequent use of Calpol 60ml. He claims that even a brief stroll aggravates his suffering, which has impeded his academic achievements. Denies vomiting or diarrhea SOAP note: Right Ankle Sprain Assignment

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Medication: Calpol 60ml 10ml PO prn

Allergy: NKFDA

PMH: no chronic illnesses reported.

Immunization: up-to-date

Family history: no significant family history was reported

Social history: The patient is the first born in a family of three children. He is currently in fourth grade at a public school nearby. He mentioned playing football with his acquaintances every weekend. No history of alcohol or tobacco use was reported. Live in a safe neighborhood with his grandmother. Eat healthy food and drink lots of water always

ROS:

General: denies fever, chills, and changes in weight.

CV: no chest pain reported

G.I.: denies nausea, vomiting, and diarrhea.

Msk: reported right ankle pain, which worsens with walking.

Neurological: denies cold or heat intolerances

O

PE:

General: Awake and oriented. Well developed and appears his stated age.

Skin: no rashes or bruises noted. SOAP note: Right Ankle Sprain Assignment

HEENT: normocephalic, EOMI. PERRLA.

CV: RRR, no murmur or galops

Msk: no significant tenderness was noted in both knees. The right ankle is swollen, and there is decreased mobility in the affected limb.

A.

Right Ankle sprain

Lab test and result

X-ray: result pending

Differential diagnoses:

1. Ankle sprain (Herzog et al.,2019).
2. Ankle fracture
3. Ankle impingement syndrome

Primary diagnoses: Ankle sprain

1. P.

Medication: Give Motrin 200mg 10ml PO TID

Non-pharmacological: use ice therapy for 15 to 20 minutes and take enough rest (Miranda et al.,2021).

Follow-up: return to the clinic if the symptoms persist or worsen for further intervention.

Referral: to the orthopedic specialist in case of complication. SOAP note: Right Ankle Sprain Assignment

References

Herzog, M. M., Kerr, Z. Y., Marshall, S. W., & Wikstrom, E. A. (2019). Epidemiology of ankle sprains and chronic ankle instability. Journal of athletic training, 54(6), 603-610.

Miranda, J. P., Silva, W. T., Silva, H. J., Mascarenhas, R. O., & Oliveira, V. C. (2021). Effectiveness of cryotherapy on pain intensity, swelling, range of motion, function and recurrence in acute ankle sprain: a systematic review of randomized controlled trials. Physical Therapy in Sport, 49, 243-249. SOAP note: Right Ankle Sprain Assignment