Engines 4 Ed



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Differential Diagnosis Form (Revised)

Patient’s Name: Jenny Anderson

Physician’s Name: Jessica Chang, M.D.

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Changes to the differential: There was no evidence of any fractures in the patient’s foot and ankle x-rays. Therefore, I ruled out lateral malleolus fracture, osteochondral fracture of the talus, Jones fracture, and fracture of the anterior process of the os calcis. Changes to the differential based on these results appear in bold.

Current Diagnosis: The most likely diagnosis for this patient is a lateral sprain. Degree of sprain is still unknown, though I am suspicious of a more severe (type 2/3) sprain given the patient’s pain and swelling.

|Diagnoses (in order of consideration) |Evidence for the Diagnosis |Evidence Against the Diagnosis |Still Under Consideration? |Rationale |

|Lateral Ankle Sprain (type 1/2/3) |ankle sprains are common in many sports | |yes |There is a close match between the |

| |lateral ankle ligaments are easily | | |findings (history, signs, symptoms, |

| |injured when the ankle turns violently | | |etc.) and this diagnosis. |

| |inward; this is what the patient | | |Lateral ankle sprain is consistent with |

| |reported | | |the mechanism of injury for this |

| |consistent with the mechanism of injury | | |patient. |

| |pain localized to lateral side of the | | |No conclusive evidence of a fracture, |

| |ankle | | |which may have similar symptoms, has |

| |swelling | | |been found. |

| |bruising | | |This is a very common injury for all |

| |difficulty walking/ bearing weight | | |levels of athletes. |

| |x-rays of the ankle showed no fracture | | | |

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|Medial Ankle Sprain (type 1/2/3) |pain |not consistent with the mechanism of |yes |Because sprains are common, I have not |

| |swelling |injury; this injury is caused by | |ruled out this diagnosis. |

| |difficulty walking/ bearing weight |rolling the foot out, away from the | | |

| | |body | | |

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|Peroneal tendon dislocation |tenderness and pain on the outer side of|peroneal tendons showed no obvious |yes |Tenderness and pain found in area of |

| |the ankle, where the tendons are found |abnormality in exam | |these tendons (peroneus longus and |

| |swelling |patient did not report feeling | |peroneus brevis). |

| |stiffness |something pop out of place | |Swelling and stiffness of ankle made it |

| |weakness | | |difficult to do proper palpation and |

| | | | |testing of the tendons; also, the |

| | | | |patient was guarding the ankle due to |

| | | | |pain. I couldn’t gather sufficient |

| | | | |information to rule out this diagnosis. |

| | | | |This diagnosis is still a possibility. |

| | | | |I may need to do further examination of |

| | | | |the tendons in a follow-up visit, if the|

| | | | |patient still has significant pain. |

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|Stress Fracture (of the tibia, |persistent pain |generally occurs due to repetitive |yes |Since this would not show up in an |

|navicular, or metatarsals) |swelling |stress, e.g. in men marching in the | |initial x-ray (stress fractures do not |

| |tenderness |army, and not typically due to a single| |show up until days or weeks later), I |

| |difficulty bearing weight |acute event | |cannot rule it out conclusively. |

| |sometimes occurs in female athletes who |no evidence of stress fracture in | | |

| |have thin bones, such as in women with |initial X-ray | | |

| |eating disorders |patient appears to be in good general | | |

| | |health and is of normal weight | | |

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|Lateral Malleolus Fracture |severe ankle pain immediately after the |no visible deformity |revised from yes to no |Since no fractures were seen in any of |

| |injury |no pain or severe tenderness or redness| |the ankle and foot x-rays, the patient |

| |severe tenderness at the injury site |localized directly over the bone | |could not have this fracture. I am |

| |swelling throughout ankle and foot |no evidence of fracture in x-rays | |ruling out this diagnosis. |

| |bruising | | | |

| |difficulty walking/ bearing weight | | | |

| |consistent with the mechanism of injury | | | |

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|Osteochondral Fracture of the Talus |severe pain in ankle appearing at the |no fracture seen in initial x-ray | | |

| |time of the injury |no fracture seen in additional views of|revised from yes to no |Since no fractures were seen in any of |

| |severe tenderness at the injury site |the ankle (anterior and oblique views) | |the ankle and foot x-rays, the patient |

| |swelling throughout ankle and foot | | |could not have this fracture. I am |

| |bruising | | |ruling out this diagnosis. |

| |great difficulty walking | | | |

| |occurs primarily in young athletes | | | |

| |consistent with the mechanism of injury | | | |

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|Jones Fracture |pain over the middle/ outside area of |no point tenderness over the base of |revised from yes to no |Since no fractures were seen in the foot|

|(fracture of the base of the 5th |the foot |the 5th metatarsal | |x-rays, I am ruling out this diagnosis. |

|metatarsal) |swelling |this fracture did not appear in any of | | |

| |difficulty walking/bearing weight |the foot x-rays | | |

| |consistent with the mechanism of injury | | | |

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|Fracture of the Os Calsis: Anterior |pain |the classic fracture of the os calcis |revised from yes to no |An anterior process fracture of the os |

|Process |tenderness |is not consistent with the mechanism of| |calsis would not be likely, but would be|

| |swelling |injury, but the patient could have had | |possible with the patient’s mechanism of|

| | |an avulsion fracture of the anterior | |injury. |

| | |process of the calcaneus (near the | |Since no fractures were seen in any of |

| | |calcaneal navicular joint) | |the ankle and foot x-rays, the patient |

| | |pain not localized to the hindfoot | |could not have this fracture. I am |

| | | | |ruling out this diagnosis. |

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|Achilles Tendon Rupture |pain |tendon felt normal when palpated |no |All evidence (especially the negative |

| |swelling |patient responded normally to Thompson | |Thompson test) indicates that patient’s |

| |difficulty walking/ bearing weight |test (foot flexed when calf muscle was | |Achilles tendon is intact. |

| |can occur with an acute injury, |squeezed) | | |

| |especially a sharp, quick movement |patient did not report feeling a | | |

| | |“whack” on the back of the ankle; this | | |

| | |is a common sensation felt with this | | |

| | |injury although there is no actual | | |

| | |contact with an object | | |

| | |condition is more common in athletic | | |

| | |men over 30 | | |

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