Left Ankle Sprain Medical Sprain

Initials of Patient:Y.G. Patient Status:New Patient Age/Sex40 years old/male           Date of Birth 09/01/78              Patient EthnicityHispanic                   Clinical Setting: Primary Care     Date of Visit:11/02/18HistorianPatientInitials of ProviderY.D.

Subjective Data

Chief Complaint:

Patient states, “I went to play basketball last night and I felt I twisted my left ankle. I didn’t feel the pain at first, but I could barely sleep because of the overnight pain. I took two ibuprofens and the pain got a little better”

History of Present Illness:

Y.G. is a 40-year-old male patient that presents to the office complaining of left ankle pain and swelling for 1 day after playing basketball last night. The patient verbalizes that he jumped and after landing he twisted his left ankle inward. The patient describes persistent pain of 5 out of 10 at rest in the left ankle with mild swelling, warm temperature and increased tenderness to touch. Pain is described as aching and moderate, getting worse with ambulation, rated as 9 out of 10 by the patient and is slightly relieved by 2 ibuprofen 400 mg tablets the patient took last night. No other associated symptoms.

Review of Systems:

Integumentary: Patient denies evidence of patches, rashes, bruising, lesions, lumps or pruritus.
Neurological: Denies evidence of sensory deficits, irritation or restlessness
ENT: Patient denies hearing impairment, vertigo, tinnitus, discharge, pain, nosebleed, nasal trauma, swallowing impairment, cough after swallowing, sore throat and hoarseness.
Eyes: Denies visual changes, light sensitivity, blurred or double vision. Patient denies loss of vision.
Cardio: Patient denies any activity intolerance, abnormal sweating, squatting, pallor or cyanosis. No chest pain, palpitations or shortness of breath
Respiratory: Denies cough, shortness of breath, sputum production, hemoptysis or night sweats.
GI: Denies poor appetite. Denies abdominal pain, changes in the stool/bowel pattern, nausea, vomiting.
GU: Patient denies evidence of genital abnormalities, penile discharge or foul odors.
Musculoskeletal: Pain with swelling to left ankle otherwise denies muscle or joint pain/tenderness, stiffness of muscles/joints, muscle cramps, deformities, backache, weakness. Patient denies numbness, tingling, muscle or joint tenderness.

Psychiatric:           Denies mood changes, nervousness, depression, therapy/counseling,

                               psychiatric disorders



Y.G. has no known allergies


Immunizations are up to date including influenza vaccine.

Past Medical History:


Past Surgical History:

Patient has no past surgical history.

Family History:

Patient lives in a house with his wife who is 36 and a daughter of age 10. Daughter has no past medical history, adequate weight and not allergic to any medication. Patient’s father died at the age of 78 of lung cancer, he was a smoker. Patient’s mother is a 75-year-old woman who suffers from hypertension and hypothyroidism. Grandparents died in Cuba “many years ago” when they were “old” of “natural causes”. Patient recently bought a German shepherd dog as a pet to his daughter.

Social History:

Y.G. is a Hispanic male from Venezuelan descent. As mentioned earlier, patient lives with his wife and his daughter in a smoke-free one-story house. The patient has a bachelor’s degree in computer science and works as an IT representative in a well-recognized hospital in the community. As a hobby patient likes to play basketball an average of two to three days a week with his friends in the local community park. Patient and his family has not travelled outside the United States in the las 30 days. Patient verbalizes a steady income, as well as wife’s support who also works as a nurse at one of the local hospitals. Patient denies smoking, use of illicit drugs and heavy drinking.

Medications Taken at home:

Medication Name Indication
Lisinopril (Prinivil) 5mg PO daily for hypertension


Level of History:

Detailed HPI (2 or more findings); ROS 9-12; PFSH 1-2 areas

Objective Data

Vital Signs and Other Measurements:

Age Gender Ethnicity Height Weight BMI
40-year old male Hispanic 6’1 180 lbs. 23
Temp HR BP RR O2Sat
97.3F 91 128/85 18 98%


Physical Exam:

General: Good posture, adequate nutritional state, with consistency in chronological and physical age, adequate emotional state. Well groomed, well-nourished and in no acute distress
Neurological: CN II to XII grossly intact; AAOX3; pinprick, light touch/vibration intact; no atrophy, tremors, or clonus; rapid alternative movement intact. Muscle tone and reflexes appear normal.  Negative Romberg sign. All deep tendon reflexes 2+. Normal speech noted.
HEENT: Facial and skull symmetry noted; normocephalic. Fontanels are closed and suture lines intact. Hair distribution normal. No lesions or scaling noted.

Conjunctiva clear with no drainage and sclera white bilaterally. Corneal light reflex and red reflex intact bilaterally. Pupils 3 and brisk, round and reactive to light and accommodation.

No redness or pain noted on pinna or auricle of ears bilaterally. No signs of foreign body entrapment or drainage in ears bilaterally. Right tympanic membrane appears translucent and pearly grey in color. Left tympanic membrane appears translucent and pearly grey in color. No tenderness, swelling or nodules around mastoid areas.

Nasal mucosa deep pink and glisten; no visible nasal discharge present.

Gingivae are moist, coral pink and intact, no lesions and carries noted. Tonsil +1 and uvula midline. Normal speech tone.

Neck: Supple neck, symmetry noted, no swelling present. Trachea midline.  Thyroid symmetrical and appropriate in size.  No carotid bruits noted.
Lungs: RR: 18.  O2 sat: 98% on room air.  No shortness of breath noted. Symmetrical chest expansion. Clear breath sounds bilaterally.
Cardio: HR: 91. S1 and S2 present, with normal rate and rhythm. No presence of heart murmurs, S3, or S4.  BP: 128/85. +2 Radial, brachial and pedal pulses. Extremities are warm and well perfused, no edema.
GI: Abdomen soft and non-distended with bowel sounds present in all four quadrants.  No masses or tenderness noted upon palpation.
GU: No costovertebral angle tenderness noted.
Musculoskeletal: Full range of motion in all extremities except in left ankle. No muscle weakness noted.  Pain on left ankle with decreased ROM, denies tingling/numbness. No spinal deformities.





Skin warm and intact, color is normal for ethnicity. No rashes or generalized edema noted.  Swelling with ecchymosis to left ankle.

No acute findings.

Denies bleeding/ dizziness, bruising to left ankle. Denies adenopathy/ tenderness/ pain/ warmth. Denies recent changes in activity level.

Diagnostic Exams:

Test Results
Left ankle radiograph There is mild soft tissue edema around the ankle with no fracture, dislocation, or suspicious osseous lesion.  The joint spaces and anatomic alignment are maintained.


Billing level of physical objective exam:

Detailed (8 organ systems see notes)


Main Diagnosis: Left ankle Sprain

Differential Diagnoses: Distal fibular fracture, chronic ankle instability and peroneal tendinitis

Risk Factors: Strenuous activity (basketball)


  1. Pharmacologic Management:
  • Ibuprofen 800mg PO every 6 hours for pain as needed
  1. Non-Pharmacologic Management: RICE. Rest, Ice, Compression, Elevation
  2. Complementary Therapies: Ace-band to left ankle. Apply ice to the affected area in sessions of 20 to 30 minutes every 3 hours for the first 2 days
  3. Health Education: Refrain from playing basketball again or exercising until cleared from health care provider. Rest as much as possible avoiding prolonged standing or walking.
  4. Referrals: Orthopedic if not better in one week
  5. Follow-up Appointment: Return to clinic in seven days for follow-up evaluation

Level of Medical Decision Making (MDM):


Risk of Complications

Acute uncomplicated illness = LAS

Prescription drug management w/ Ibuprofen 800mg

Moderate>Low (p.6)



Amount/Complexity of Data Reviewed/Ordered None N/A
No. Diagnoses/Treatment New problem, No additional W/U planned (3)



Total Score: 3 = Moderate Complexity (Florida International University-HCN,

2012, p.6)


Final Billing Level:

Level 4- 99204

Patient Status:  New

Level of history: Detailed

Level of physical (exam): Detailed

Level of Medical decision-making: Moderate

(Florida International University-HCN, 2012, p.7)

ICD-10-CM Code: Sprain of unspecified ligament of left ankle: S93.402A

Subjective Analysis

According to research, ankle ligament sprain appears to be the most common ankle injuries seen in the primary setting (Doperak & Anderson, 2018). Around 80% of it includes the lateral ankle ligaments: anterior talofibular ligament, the calcaneofibular ligament, and the posterior talofibular ligament. Generally, these pathologies occur after the ankle is placed under extreme inversion and plantar flexion (Doperak & Anderson, 2018). Another type of ankle sprain called Syndesmotic or high ankle sprain is cataloged dorsiflex and everted, bringing along with it a prolonged recovery in which early identification of the disease is of crucial importance for its correct diagnosis and treatment. At the same time, medial ankle sprains are less common while involving the deltoid ligament complex (Doperak & Anderson, 2018). Patients usually report an ankle turning during a fall or when landing in an irregular surface like a hole or other surface. According to Luke and Ma (2018), women have a tendency to experience an inversion injury more often than men. That same author references that up to 43% of ankle sprain can still remain ill after 6 months of continuous physical therapy, which makes early identification and diagnosis of superb importance in the treatment of ankle sprain (Luke & Ma, 2018). Y.G.’s active lifestyle has put him at risk for this type of injuries. Ankle Sprains can affect from children to older adults, athletes and non-athletes, it can occur during vigorous sports or simply taking a bad step off a curb (Bruene, 2014). According to Peterson et al., (2013), the mixture of inversion and adduction of the foot in plantar flexion is the most common mechanism of injury.

Objective Analysis

In order to accomplish an accurate evaluation of an ankle sprain a careful history taking is a requirement. Is it important to find out the mechanism of the injury to further plan the care, whether or not the patient could walk after the injury to further stratify the risk of fracture, and whether the ankle has been injured before or it is a primary injury (Maughan, Eiff, & O’Connor, 2018). A physical examination consists on an inspection, palpation of the extremity as well as the capacity to bear weight, and injury specific physical diagnostic tests. Tenderness should be assessed taking into consideration the “Ottawa ankle rule” areas which include posterior tip or edge of the lateral malleolus, posterior tip or edge of the medial malleolus, base of the fifth metatarsal, and navicular bone (Maughan, Eiff, & O’Connor, 2018). Furthermore, pain associated with the distal tibia or fibula may represent a fracture linked to eversion or inversion injuries (Maughan, Eiff, & O’Connor, 2018).

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Several intrinsic and extrinsic risks factors have been associated with ankle sprains. Literature reveals that patient related risk factors or intrinsic in ankle sprain include limited dorsiflexion, balance deficiencies and reduced proprioception. On the other hand, environmental factor that can prone a patient to ankle sprains are mainly related to the type of sport the patient practices, being indoor court sports the ones posing the highest risk (Maughan, Eiff, & O’Connor, 2018). According to the evidence, sports that contribute to ankle sprain the most include indoor volleyball, basketball, aero ball, field sports, and climbing. In order to decrease the risk of recurrent injuries, modifiable factors should be identified and addressed as part of a prevention and rehabilitation program (Maughan, Eiff, & O’Connor, 2018).

Assessment Analysis

Upon physical examination Y.G. presents with swelling of the left ankle with limited range of motion, ecchymosis and tenderness to touch. An x-ray reports mild soft tissue edema around the area of the left ankle with no fracture, dislocation, or suspicious osseous trauma. Anatomic alignment and joint spaces are maintained with no open wounds noted. After a physical examination, an x-ray diagnostics test, and the presentation of symptoms the diagnosis is consistent with a left ankle sprain. A marked difference between ankle sprains and strains is that strains are injuries that occur directly to the ankle muscles and their connecting tendons are stretched beyond their normal limits while sprains are caused by direct trauma to the ankle ligament (Bruene, 2014).

According to literature several differential diagnoses for left ankle sprain can be mentioned. The most popular include distal fibular fracture, chronic ankle instability and peroneal tendinitis (Cardell & O’Rorke, 2018). Fractures of the distal fibular occur frequently in children. This injury is the equivalent of an ankle sprain in the skeletally mature individual. Physical examination localizes tenderness to the distal fibular growth plate, and radiographs will typically be interpreted as normal (Cardell & O’Rorke, 2018). A chronic ankle instability can be considered if an ankle sprain pain or associated injuries pain than 3 months (Doperak & Anderson, 2018). Tendonitis of the peroneus longus may be associated with abnormality of the os peroneum, a small sesamoid bone located in the tendon where it curves around the lateral border of the cuboid (Luke & Ma, 2018).

Plan Analysis

Most lateral ankle ligament sprain can be treated the same way. First interventions consist on the control of pain and swelling while maintaining range of motion before gradually increasing exercise. For the first two days RICE (Rest, Ice, Compression and Elevation) is recommended. Rest can be achieved by limiting weightbearing. Apply compression with an elastic bandage to minimize swelling as early as possible on treatment as well as leg elevation above the level of the heart (Maughan, Eiff, & O’Connor, 2018). Pharmacological treatment consists on NSAIDS for analgesia. Research is in favor of both oral or topical since both are more effective that placebo on clinical trials (Maughan, Eiff, & O’Connor, 2018). There are no current studies comparing NSAIDs analgesics vs no NSAIDS analgesics (acetaminophen) which brings to the conclusion that the antiinflammatory effect is not clearly important. Finally exercise and physical therapy appear as the mainstay in the recovery of an ankle sprain. Range of motion exercises including plantar flexion, dorsiflexion, and foot circles should be started early, once acute pain and swelling subside. The intensity of rehab exercises should be gradually increased. Splints and braces should be worn since it can limit extremes of joint motion and allow early weightbearing while protecting reinjury (Maughan, Eiff, & O’Connor, 2018).

Prescription # 1

Name: Y.G. DOB 09/01/78

Address: 2815 SW 78th Miami, FL 33178

Ibuprofen 800mg

1 tablet PO (by mouth) every 6 hours for pain as needed

Disp # 40 (forty)

Refills # none  Signature: Yeniell Diaz ARNP NPI # 1234567890 Date: 11/02/2018



  • Bruene, J. R. (2014). Ankle Sprain and Strain Signs and Symptoms. Retrieved from //www.sports-health.com/sports-injuries/ankle-and-foot-injuries/ankle-sprain-and-strain-signs-and-symptoms
  • Cardell, D., & O’Rorke, J. E. (2018). The Patient History: An Evidence-Based Approach to Differential Diagnosis. New York: Lange.
  • Doperak, J., & Anderson, K. (2018). Current Diagnosis and Treatment. New York: McGraw & Hill Ltd.
  • Florida International University- HCN (2012). Documentation and coding guideline for health care professionals. Coding Compliance, 4-7.
  • Luke, A., & Ma, B. (2018). Current Medical Diagnosis and Treatment: Sports Medicine and Outpatient Orthopedics. New York: McGraw & Hill Ltd.
  • Maughan, K. L., Eiff, P., & O’Connor, F. G. (2018, October 15). Ankle Sprain. Retrieved from Uptodate: //www.uptodate.com/contents/ankle-sprain?search=ankle%20sprain&source=search_result&selectedTitle=1~35&usage_type=default&display_rank=1





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