Respond to  your colleague . Analyze the possible conditions from your colleagues’ differential diagnoses. Determine which of

Respond to  your colleague . 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

Please Respond to the post. Use references, please.’

Patient Information:
Jane, 46, Female, Caucasian
 
SUBJECTIVE DATA:
Chief Complaint (CC):  “I hurt my ankle.”
History of Present Illness (HPI):  JD is a 46-year-old Caucasian female who presents to the clinic today complaining of new onset ankle pain. She reports the pain is present in both ankles but more pronounced in the right ankle. The pain does not radiate to the foot or leg, but is confined to the ankle area. She describes the pain as sharp and uncomfortable, especially when she is weight-bearing. She currently denies pain but states it has been as high as 9/10 when she tries to walk. The pain began this past weekend while she was playing soccer. She is able to bear weight but it is painful to do so. Ambulation exacerbates the discomfort. Rest, ice, and ibuprofen partially relieve it. She denies any overt injury to her ankle, but states she heard a “pop” while playing soccer.
Medications:
Prozac, 20mg daily
Ibuprofen (OTC) 600mg twice daily as needed for pain
Allergies:  Codeine (nausea and vomiting)
Past Medical History (PMH):
Depression (diagnosed 6 years ago)
Past Surgical History (PSH): Denies.
Sexual/Reproductive History: Heterosexual, no children, LMP 7/1/2021.
Personal/Social History:  Unmarried, in a long-term relationship. Partner is supportive. Catholic faith. Employed as an auditor at a local firm. No past or present tobacco use, reports drinking 2-3 alcoholic beverages (wine) per week, denies use of marijuana, cocaine, heroin, or other illicit drugs. Enjoys soccer, swimming, and reading. She is insured and denies financial barriers to healthcare.
Immunization History: Tdap 10/2016, influenza vaccine this season.
Significant Family History:
Father – GERD, hyperlipidemia, obesity, age 72
Mother – osteoporosis, age 70
Brother – healthy, age 48
Maternal grandmother – osteoporosis, osteoarthritis, age 91
Maternal grandfather – died of a heart attack at age 55
Paternal grandmother – died of pneumonia at age 75
Paternal grandfather – died of natural causes at age 85
 
Review of Systems:
General: Denies fever, chills, fatigue, night sweats, weight loss/gain, dizziness, palpitations.
Cardiovascular/Peripheral Vascular: Denies a history of hypertension or other cardiac problems. Denies generalized edema, blood clots, circulation problems.
                Respiratory: Denies shortness of breath, cough, wheezing.
                Gastrointestinal: Denies nausea, vomiting.
Musculoskeletal: Denies history of osteoarthritis, RA, joint stiffness. Reports acute right ankle pain with ambulation, ankle flexion, inversion/eversion.  Reports ROM intact. Reports edema and bruising to right ankle. Denies numbness, paresthesia.
Psychiatric: Denies depression and anxiety. States that prescribed SSRI is effective in managing symptoms of depression.
 
OBJECTIVE DATA:
Physical Examination:
Vital signs: BP 130/80 (rt. arm), HR 90, R 18, O2 98% ORA, T 36.7, BMI 22 (normal).
General: JD is a well-groomed Caucasian female who appears her stated age. She is alert, oriented, and in no acute distress. She is calm and cooperative. She answers questions appropriately and presents as a reliable historian for this examination.
Cardiovascular/Peripheral Vascular:  No JVD or peripheral edema noted (excluding swelling to right ankle). Capillary refill < 3 seconds. No bruit/thrill. S1 and S2 audible upon auscultation. No murmurs or gallops noted. Pulses intact.
Respiratory: Breath sounds present in all areas. No adventitious sounds auscultated.
Gastrointestinal:  Abdomen soft, nontender. Normoactive bowel sounds presents x4 quadrants.  
Musculoskeletal: No bony deformities noted.  No pes planus.  Full ROM dorsi/plantar flexion, inversion and eversion (although this is associated with acute pain). Pt is unable to bear weight comfortably for more than 4 steps on right foot/ankle. Significant edema noted right ankle. Anterior drawer test positive.
Neurological: Oriented to all spheres.
Skin: Diffuse discoloration/ecchymosis noted over lateral aspect of right ankle.
 
 
 
Diagnostic Test/Labs with Rationale:
CBC, erythrocyte sedimentation  rate – to determine baseline health, inflammation
Xray – to assess bone fracture
MRI – to assess soft tissue injury
According to the Ottawa Ankle Rules, radiographs are justified when one of three conditions occurs in conjunction with malleolar pain: bone tenderness along the distal 6cm of the posterior edge of the fibula or tip of the lateral malleolus;  bone tenderness along the distal 6cm of the posterior edge of the tibia or tip of the medial malleolus;  and, inability to bear weight for four steps both immediately after the injury and in the emergency department (Ball et al., 2019). The Ottawa Ankle Rules have a 98.5% sensitivity for detecting and ankle fracture that is present on radiography (Ball et al., 2019).
ASSESSMENT:
Primary diagnosis = Grade 3 Ankle Sprain
Differential diagnoses:
1.       Grade 3 Ankle Sprain (r/t inversion injury)
The talofibular ligament is one of the lateral ligaments of the ankle. It is the most commonly injured ligament in a sprained ankle—from an inversion injury—and will allow a positive anterior drawer test of the ankle if completely torn (Larkins et al., 2020). This patient has a positive anterior drawer test.
A Grade 3 ankle sprain is a complete tear of the ligament. Patients often report hearing a “popping” sound at the time of the injury (as this patient did). This level of pain causes severe pain, swelling and bruising (Suo et al., 2020). Due to ankle instability, the patient is often unable to bear weight on the affected limb. This patient is able to bear weight, but it is extremely painful and she is unable to take more than a few steps. With a Grade 2 sprain, the ligament is partially torn. Imaging will provide further information to support a diagnosis and determine the severity of the sprain. THE PATIENT SHOULD BE REFERRED TO AN ORTHOPEDIST.
Of note, this patient initially presented with bilateral ankle pain. She plays soccer and has, most likely, strained her joints. An ankle strain occurs due to the overstretching of muscles surrounding a joint (as opposed to the tearing of ligaments which connect bones). Prolonged, repetitive motion and athletic  activities are common causes of strains (Holland, 2017).
2.       Ankle Fracture
3.       Osteoarthritis
4.       Achilles Tendonitis
5.       Peroneal Tendon Subluxation
6.       Calcaneofibular Ligament Injury
 
References:
Ball, J. W., Dains, J. E., Flynn,  J. A., Solomon, B. S.,