NURS 6512 Advanced Health Assessment and Diagnostic
Reasoning Week 8: Assessment of the
Musculoskeletal System
Case Study #2
A 46-year-old female with complaints of pain in both of her ankles, but more pain and
concern about the right ankle. She heard a “pop” when she was playing soccer this past
weekend. She has the ability to bear weight but has discomfort when she does.
Patient Information:
Name: TR Age: 46-year-old Sex: Female Race: Caucasian
S.
CC: “My ankles hurt but is much worse on the right side”
HPI: TR is a 46-year-old Caucasian female who presents to the clinic with bilateral ankle pain
for the past 2 days. The pain started after she was playing soccer over the weekend and noticed a
pop sound while playing. The pain feels like it is throbbing and achy. She can bear weight on
both ankles but noticed the discomfort is worse on the right side. Her pain is a 5/10 in both
ankles but increases to a 7/10 on the right side when walking or standing. Elevation and
applying ice packs have provided relief but she has noticed her right ankle has become swollen.
Currently her pain is 6/10 on her right ankle and 2/10 on the left side.
Current Medications:
1. Multivitamin PO daily
2. Ibuprofen 200mg-2 PO PRN for pain
3. Tylenol 325mg-2 PO PRN for pain
4. Oral contraceptive 1 PO daily in the morning unsure of the name.
Allergies: NKA
PMHx: Right ankle sprain in 2012, no surgical history, immunizations are up to date and last
influenza vaccine was this season. Tetanus was 2 years ago. Last menstrual period was 28 days
ago.
Soc Hx: She works as a middle school teacher and coaches the girls’ soccer team. She is single.
, She drinks alcohol occasionally. Denies smoking and recreational drug use.
Reasoning Week 8: Assessment of the
Musculoskeletal System
Case Study #2
A 46-year-old female with complaints of pain in both of her ankles, but more pain and
concern about the right ankle. She heard a “pop” when she was playing soccer this past
weekend. She has the ability to bear weight but has discomfort when she does.
Patient Information:
Name: TR Age: 46-year-old Sex: Female Race: Caucasian
S.
CC: “My ankles hurt but is much worse on the right side”
HPI: TR is a 46-year-old Caucasian female who presents to the clinic with bilateral ankle pain
for the past 2 days. The pain started after she was playing soccer over the weekend and noticed a
pop sound while playing. The pain feels like it is throbbing and achy. She can bear weight on
both ankles but noticed the discomfort is worse on the right side. Her pain is a 5/10 in both
ankles but increases to a 7/10 on the right side when walking or standing. Elevation and
applying ice packs have provided relief but she has noticed her right ankle has become swollen.
Currently her pain is 6/10 on her right ankle and 2/10 on the left side.
Current Medications:
1. Multivitamin PO daily
2. Ibuprofen 200mg-2 PO PRN for pain
3. Tylenol 325mg-2 PO PRN for pain
4. Oral contraceptive 1 PO daily in the morning unsure of the name.
Allergies: NKA
PMHx: Right ankle sprain in 2012, no surgical history, immunizations are up to date and last
influenza vaccine was this season. Tetanus was 2 years ago. Last menstrual period was 28 days
ago.
Soc Hx: She works as a middle school teacher and coaches the girls’ soccer team. She is single.
, She drinks alcohol occasionally. Denies smoking and recreational drug use.
