Directions: Read over the SOAP note and formulate a primary diagnosis. Based on the diagnosis complete the SOAP note with the details that would be expected for the diagnosis. Use UptoDate and/or Dyna MedPlus to find out what is expected from the history and physical, diagnostic workup and management for the diagnosis. Include other peer review resources and and journal articles to support the development of your SOAP note. Complete and attach the evaluation & management score sheet to show how you coded the note for billing in each section.
Case Study: A 47-year-old African-American man presents to your office for a follow-up visit. He was seen 3 weeks ago for an upper respiratory infection and noted incidentally to have a blood pressure of 164/98 mm Hg. He vaguely remembered being told in the past that his blood pressure was “borderline.” He feels fine, has no complaints, and his review of systems is entirely negative. He does not smoke cigarettes, drinks “a couple of beers on the weekends,” and does not exercise regularly. He has a sedentary job. His father died of a stroke at the age of 69. His mother is alive and in good health at the age of 72. He has two siblings and is not aware of any chronic medical issues that they have. In the office today, his blood pressure is 156/96 mm Hg in his left arm and 152/98 mm Hg in the right arm. He is afebrile, his pulse is 78 beats/min, respiratory rate 14 breaths/min, he is 70-in tall, and weighs 210 lb. A general physical examination is normal.
SOAP NOTE GRADING RUBRIC
Guidelines:
SUBJECTIVE Analysis (0.2 POINT)
Score received
1-Subjective section should include:
a-Chief complaint (CC)
b-History of present illness (HPI)- All 7 attributes (location, quality, quantity or severity, timing including onset, frequency, and duration, setting in which it occurs, aggravating or relieving factors, and associated symptoms)
c-Past history (Medical, Surgical, Obstetric/Gynecology, Psychiatric)
d-family history (3 generation pedigree of first-degree relatives, i.e. parents, siblings, children)
e. Personal and social history (i.e. sexual history 5p’s)
f. Review of systems (ROS, pertinent positives and/or negatives)
g. Developmentally appropriate-i.e. developmental history if peds, functional assessment and/or dementia screen if elderly
a-Identified and collected the necessary data
b-Categorized and organized data using the appropriate format
c-Incorporated all pertinent data/facts
d- Used proper documentation and proper billing code
e- PATIENT’S CULTURE MUST BE NOTED
OBJECTIVE (0.2POINT)
Score received
1-Objective section should include:
a. General survey
b. Vital Signs (including BMI and growth chart if applicable)
c. All other necessary body systems
d. Diagnostic test if available
a. Identified and collected the necessary data
b. Categorized and organized data using the appropriate format
c.Incorporated all pertinent data/facts
d. Used proper documentation and billing code
ASSESSMENT (0.2 POINT)
Score received
1- Identified correct diagnosis, ICD-10 code, and correct differential diagnosis
a-Filtered relevant data from irrelevant data
b.-Interpreted relationships/patterns among data
(e.g., noted trends)
c.Integrated information to arrive at diagnosis
d.Identified risk factors
d. Used proper documentation
PLAN Analysis (0.2POINT)
Score received
a-Recommended an appropriate plan for each problem
b-Included recommendations for non-drug and drug therapy
c-Included recommendations for monitoring
d- Included health education
e- Included followup & referrals
f- include cultural considerations of patient care
Incorporate the patient’s culture on the demographic section on SOAP notes.
FORMAT (0.2 POINT)
Score received
1- APA
2- References Current (atleast two references, one of which needs to be uptodate and the other a clinical practice guideline from a peer reviewed journal article or national organization such as AAFP, ACOG, USPSTF)
3- Writing clear, concise
4- Summary/Conclusion
TOTAL: /1
SOAP FORMAT & RUBRIC
Initials of Patient:
Patient Age:
Patient Ethnicity:
Initials of Provider:
Clinical Setting:
Patient Status: ____New ____Established
SUBJECTIVE DATA; GRADE RECEIVED: _____
Overall Instructions:
1.
Identified and collected the necessary data
2.
Categorized and organized data using the appropriate format
3.
Incorporated all pertinent data/facts
4.
Used proper documentation
5.
LIST at the end of your subjective section the billing level : Problem Focused, Expanded problem focused, detailed, comprehensive (use guidelines for new vs. established patient
6.
Identify cultural influences on care
FORMAT
Chief Complaint:
History of Present Illness:
Location
Quality
Quantity or Severity
Timing (Onset, Duration, Frequency)
Setting
Aggravating and relieving Factors
Associated Symptoms
Past history (include dates):
PMH
·
Chronic illness (date of onset) & hospitalizations (dates) Medications: Dose, route, frequency
·
Allergies: Medications, Foods, Other Allergens
PSH
·
(Dates, indications, and types of operations)
Past Psychiatric Hx
·
(Illness and timeframe, diagnosis, hospitalizations and treatments)
Obstetrical/Gynecological (obstetric history & menstrual history) Obstetrical History
·
(Gravida-Para-TPAL)
Menstrual History
·
(Menarche, LMP, PMP, regular/irregular, frequency, duration, quality of flow, Menopause, Post-menopausal bleeding, HRT)
Health Promotion/Maintenance: Colonoscopy, Prostate (PSA), BP
check, Cholesterol, Annual Physical, Mammography, PAP, Eye
Exam, Dental etc., Immunizations
Functional Status: ADLs and IADLs
Family History: Alive, Deceased, Age, Diseases, Health Conditions that place patient at risk (ages)
Parents
Siblings
Children
Social History:
Cultural Background
Spiritual History/Religious Affiliation and Practices
Complementary/Alternative Care Practices:
Type of Family (Nuclear, Extended etc.)
Marital Status
Parental Status
Work History
Financial History
Diet
Exercise (Frequency, intensity, Time, Type)
Stress Management
Sleep
Social Support
Sexual history (5ps)
Use of alcohol, smoking, or recreational drugs
Living Arrangements
Travel History
Review of Systems:
Constitutional:
Head/face:
Eyes:
Ears:
Nose:
Mouth/Throat/ Neck:
Respiratory:
Cardiac:
Breast:
GI:
GU:
GYN (female):
Reproductive (Male):
Musculoskeletal:
Skin/Integument:
Psychiatric:
Neuro:
Endocrine:
Hematologic/Lymphatic:
Allergic/Immunologic:
Determine Which LEVEL of HISTORY (Choose one):
Focused HPI (1-3 findings); ROS N.A; PFSH N.A
Expanded HPI (1-3 Findings); ROS 1 or more; PFSH N.A.
Detailed HPI (4 or more findings); ROS 2-9 systems; PFSH one
Comprehensive HPI (4 or more findings or status of 3 or more chronic stable conditions; ROS 10-14; PFSH 2-3 areas
OBJECTIVE DATA; Grade received_____
Overall Instructions:
1.
Identified and collected the necessary data
2.
Categorized and organized data using the appropriate format
3.
Incorporated all pertinent data/facts
4.
Used proper documentation
5.
LIST at the end of your subjective section the billing level : Problem Focused, Expanded problem focused, detailed, comprehensive (use guidelines for new vs. established patient
FORMAT:
Vital Signs:
Oxygen Saturation:
Ht:
Wt:
BMI:
Constitutional:
General:
Physical Examination:
Head/face:
Eyes:
Ears:
Nose:
Mouth/Throat/ Neck:
Respiratory:
Cardiac:
Breast:
GI:
GU:
GYN (female):
Reproductive (Male):
Musculoskeletal:
Skin/Integument:
Psychiatric:
Neuro:
Hematologic/Lymphatic/Immunologic:
Determine Billing LEVEL OF PHYSICAL OBJECTIVE EXAM (choose one):
Focused: 1 body area or organ system (1-5 elements);
Expanded problem focused (2-4 body are or organ system (6-11 elements);
Detailed (5-7 see notes);
Comprehensive (8 organ systems see notes);
Laboratory Data Already Ordered and Available for Review (If not done will go in plan):
Diagnostic Procedures/Data Already Ordered and Available for Review (If not done will go in plan):
ASSESSMENT; GRADE RECEIVED____
1)
Main Diagnosis/Problem:
2)
Additional Health Problem/Dx:
3)
Differential Diagnoses for top diagnoses
4)
Identify Risk Factors
PLAN; GRADE RECEIVED________
For Each Diagnosis or Health Problem Identified as Appropriate:
Additional Laboratory Tests or Diagnostic Data Needed
Pharmacologic Management:
Drug, dose, route, frequency, Disp amount
SIG (write like a prescription)
Non-Pharmacologic Management: i.e. hot packs, ice, position changes, TENS unit etc.
Complementary Therapies:
Health Education:
Referrals:
Follow-up Appointment:
For the Encounter Final Level of Decision Making: (give rationale for level which is based on Hx, physical, Decision making); Choose one
Straightforward:
Low Complexity:
Moderate Complexity:
High Complexity:
Billing Level: Give the reason for the Billing by E and Coding as per Number of Systems Reviewed and Level of Physical Exam.
Patient Status: New or established
Level of history
Level of physical (exam)
Level of Medical decision making
E/M Documentation Auditor’s Instructions
1. History
Refer to data section (table below) in order to
q
uantify. After referring to data, circle the entry farthest to the RIGHT in the table, which
best describes the HPI, ROS and PFSH. If one column contains three circles, draw a line down that column to the bottom row to
identify the type of history. If no column contains three circles, the column containing a circle farthest to the LEFT, identifies the type
of history.
After completing this table which classifies the history, circle the type of history within the appropriate grid in Section 5.
HPI: Status of chronic conditions:
q 1 condition q 2 conditions q 3 conditions
q
Status of
1-2 chronic
Status of 3
chronic
conditions conditionsOR
HPI (history of present illness) elements:
q Location q Severity q Timing q Modifying factors
q Quality q Duration q Context q Associated signs and symptoms
q
Brief
(1-3)
Extended
(4 or more)
ROS (review of systems):
q Constitutional q Ears,nose, q GI q Integumentaryq Endo
(wt loss, etc) mouth, throat q GU (skin, breast) q Hem/lymph
q Eyes q Card/vasc q Musculo q Neuro q All/immuno
q Resp q Psych q All others negative
q
None
q
Pertinent to
problem
(1 system)
q
Extended
(2-9 systems)
*Complete
PFSH (past medical, family, social history) areas:
q Past history ( the patient’s past experiences with illnesses, operation, injuries and treatments)
q Family history (a review of medical events in the patient’s family, including diseases which may be
hereditary or place the patient at risk)
q Social history (an age appropriate review of past and current activities)
plete ROS: 10 or more systems or the pertinent positives and/or negatives of
q
None
q
Pertinent
(1 history area)
e**Complet
y(2 or 3 histor
areas)
PROBLEM
FOCUSE
D
EXP.PROB.
FOCUSED DETAILED -COMPRE
HENSIVE
q
T
O
R
Y
I
S
H
*Com
some systems with a statement “all others negative”.
**Complete PFSH: 2 history areas: a) Established Patients – Office (Outpatient) Care; b) Emergency Department.
3 history areas: a)
New
Patients – Office (Outpatient) Care, Domiciliary Care, Home Care; b) Initial Hospital Care;
c) Initial Hospital Observation; d) Initial Nursing Facility Care.
NOTE:For certain categories of E/M services that include only an interval history, it is not necessary to record
information about the PFSH. Please refer to procedure code descriptions.
2. Examination
Refer to data section (table below) in order to quantify. After referring to data, identify the type of examination.
Circle the type of examination within the appropriate grid in Section 5.
Limited to affected body area or organ system (one body area or system related to problem) PROBLEM FOCUSED EXAM
Affected body area or organ system and other symptomatic or related organ system(s)
(additional systems up to total of 7)
EXPANDED PROBLEM
FOCUSED EXAM
Extended exam of affected area(s) and other symptomatic or related organ system(s)
(additional systems up to total of 7 or more depth than above) DETAILED EXAM
General multi-system exam (8 or more systems) or complete exam of a single organ system
(complete single exam not defined in these instructions) COMPREHENSIVE EXAM
A
M
E
X
Body areas:
q Head, including face q Chest, including breasts and axillae
q Back, including spine qGenitalia, groin, buttocks
Organ systems:
q
q
Abdomen q Neck
Each extremity
q q q
1 body
area or
system
Up to 7
systems
Up to 7 8 or more
systems systems
q Constitutional q Ears,nose, q Resp q Musculo q Psych
) (e.g., vitals, gen app mouth, throat q GI q Skin
q Eyes q Cardiovascular q GU q Neuro
q Hem/lymph/imm
PROBLEM
FOCUSED
EXP.PROB.
FOCUSED DETAILED COMPRE-
HENSIVE
q
– 1 –
q
q
q
3. Medical Decision Making
Number of Diagnoses or Treatment Options
Identify each problem or treatment option mentioned in the record.
Enter the number in each of the categories in Column B in the table
below. (There are maximum number in two categories.)
Number of Diagnoses or Treatment Options
A B X C = D
Problem(s) Status Number Points Result
Self-limited or minor
(stable, improved or worsening) Max = 2
1
Est. problem (to examiner); stable, improved 1
Est. problem (to examiner); worsening
2
New problem (to examiner); no additional
workup planned
Max = 1
3
New prob. (to examiner); add. workup planned 4
TOTAL
Multiply the number in columns B & C and put the product in column D.
Enter a total for column D.
Bring total to line A in Final Result for Complexity (table below)
Amount and/or Complexity of Data Reviewed
For each category of reviewed data identified, circle the number in the points
column. Total the points.
Amount and/or Complexity of Data Reviewed
Reviewed Data Points
1
1
1
1
1
2
2
Review and/or order of clinical lab tests
Review and/or order of tests in the radiology section of CPT
Review and/or order of tests in the medicine section of CPT
Discussion of test results with performing physician
Decision to obtain old records and/or obtain history from
someone other than patient
Review and summarization of old records and/or obtaining
history from someone other than patient and/or discussion of
case with another health care provider
Independent visualization of image, tracing or specimen itself
(not simply review of report)
TOTAL
Bring total to line C in Final Result for Complexity (table below)
Use the risk table below as a guide to assign risk factors. It is understood that the table below does not
contain all specific instances of medical care; the table is intended to be used as a guide. Circle the
most appropriate factor(s) in each category. The overall measure of risk is the highest level circled.
Enter the level of risk identified in Final Result for Complexity (table below).Risk of Complications and/or Morbidity or Mortality
Level of
Risk
Presenting Problem(s) Diagnostic Procedure(s)
Ordered
Management Options
Selected
Minimal
• One self-limited or minor problem,
e.g., cold, insect bite, tinea corporis
• Laboratory tests requiring venipuncture
• Chest x-rays
• EKG/EEG
• Urinalysis
• Ultrasound, e.g., echo
• KOH prep
• Rest
• Gargles
• Elastic bandages
• Superficial dressings
Low
• Two or more self-limited or minor problems
• One stable chronic illness, e.g., well controlled
hypertension or non-insulin dependent diabetes,
cataract, BPH
• Acute uncomplicated illness or injury, e.g., cystitis, allergic
rhinitis, simple sprain
• Physiologic tests not under stress, e.g.,pulmonary
function tests
• Non-cardiovascular imaging studies with contrast,
e.g., barium enema
• Superficial needle biopsies
• Clincal laboratory tests requiring arterial puncture
• Skin biopsies
• Over-the-counter drugs
• Minor surgery with no identified risk factors
• Physical therapy
• Occupational therapy
• IV fluids without additives
Moderate
• One or more chronic illnesses with mild exacerbation,
progression, or side effects of treatment
• Two or more stable chronic illnesses
• Undiagnosed new problem with uncertain prognosis,
e.g., lump in breast
• Acute illness with systemic symptoms, e.g.,
pyelonephritis, pneumonitis, colitis
• Acute complicated injury, e.g., head injury with brief loss
of consciousness
• Physiologic tests under stress, e.g., cardiac stress test,
fetal contraction stress test
• Diagnostic endoscopies with no identified risk factors
• Deep needle or incisional biopsy
• Cardiovascular imaging studies with contrast and no
identified risk factors, e.g., arteriogram cardiac cath
• Obtain fluid from body cavity, e.g., lumbar puncture,
thoracentesis, culdocentesis
• Minor surgery with identified risk factors
• Elective major surgery (open, percutaneous or
endoscopic) with no identified risk factors
• Prescription drug management
• Therapeutic nuclear medicine
• IV fluids with addititives
• Closed treatment of fracture or dislocation without
manipulation
High
• One or more chronic illnesses with severe exacerbation,
progression, or side effects of treatment
• Acute or chronic illnesses or injuries that may pose a threat to
life or bodily function, e.g., multiple trauma, acute MI,
pulmonary embolus, severe respiratory distress, progressive
severe rheumatoid arthritis, psychiatric illness with potential
threat to self or others, peritonitis, acute renal failure
• An abrupt change in neurologic status, e.g., seizure, TIA,
weakness or sensory loss
• Cardiovascular imaging studies with contrast with
identified risk factors
• Cardiac electrophysiological tests
• Diagnostic endoscopies with identified risk factors
• Discography
• Elective major surgery (open, percutaneous or
endoscopic with identified risk factors)
• Emergency major surgery (open, percutaneous or
endoscopic)
• Parenteral controlled substances
• Drug therapy requiring intensive monitoring for toxicity
• Decision not to resuscitate or to de-escalate care
because of poor prognosis
Final Result for Complexity
Draw a line down any column with 2 or 3 circles to identify the type of decision making in
that column. Otherwise, draw a line down the column with the 2nd circle from the left.
After completing this table, which classifies complexity, circle the type of decision
making within the appropriate grid in Section 5.
Final Result for Complexity
A Number diagnoses or
treatment options
≤ 1
Minimal
2
Limited
3
Multiple
≥ 4
Extensive
B Highest Risk Minimal Low Moderate High
C Amount and complexity
of data
≤ 1
Minimal
or low
2
Limited
3
Multiple
≥ 4
Extensive
Type of decision making STRAIGHT-
FORWARD
LOW
COMPLEX.
MODERATE
COMPLEX.
HIGH
COMPLEX.
4. Time
If the physician documents total time and suggests that counseling or coordinating care dominates
(more than 50%) the encounter, time may determine level of service. Documentation may refer to:
prognosis, differential diagnosis, risks, benefits of treatment, instructions, compliance, risk
reduction or discussion with another health care provider.
Face-to-face in outpatient setting
Does documentation reveal total time? Time: Unit/floor in inpatient setting Yes No
Does documentation describe the content of counseling or coordinating care? Yes No
Does documentation reveal that more than half of the time was counseling or
coordinating care? Yes No
If all answers are “yes”, select level based on time.
– 2 –
M
E
D
I
C
A
L
D
E
C
I
S
I
O
N
M
A
K
I
N
G
5. L E V E L O F S E R V I C E
New Office, Outpatient and Emergency Room
New Office / Outpatient / ER Established Office / Outpatient
Requires 3 components within shaded area Requires 2 components within shaded area
History
PF
ER: PF
EPF
ER: EPF
D
ER: EPF
C
ER: D
C
ER: C Minimal
problem
that may
not
require
presence
of
physician
PF EPF D C
Examination
PF
ER: PF
EPF
ER: EPF
D
ER: EPF
C
ER: D
C
ER: C
PF EPF D C
Complexity
of medical
decision
SF
ER: SF
SF
ER: L
L
ER: M
M
ER: M
H
ER: H SF L M H
Average time
(minutes)
ER has no average
time
10 New (99201)
ER (99281)
20 New (99202)
ER (99282)
30 New (99203)
ER (99283)
45 New (99204)
ER (99284)
60 New (99205)
ER (99285)
5
(99211)
10
(99212)
15
(99213)
25
(99214)
40
(99215)
Level I II III IV V I II III IV V
Hospital Care Initial Hospital/Observation Subsequent Hospital/Observation
Requires 3 components within shaded area Requires 2 components within shaded area
History D/C C C PF interval EPF interval D interval
Examination D/C C C PF EPF D
Complexity of medical
decision SF/L M H SF/L M H
Average time (minutes)
30 Init hosp (99221)
30 Init observ Care
(99218)
50 Init hosp (99222)
50 Init observ Care
(99219)
70 Init hosp (99223)
70 Init observ Care
(99220)
15 Sub hosp (99231)
15 Sub observ care
(99224)
25 Sub hosp (99232)
25 Sub observ care
(99225)
35 Sub hosp (99233)
35 Sub observ care
(99226)
Level I II III I II III
Nursing Facility
Care Initial Nursing Facility
Requires 3 components within shaded area
Subsequent Nursing Facility
Requires 2 components within shaded area
Other Nursing Facility
(Annual Assessment)
Requires 3 components within shaded area
History D/C C C PF interval EPF interval D interval C interval D interval
Examination D/C C C PF EPF D C C
Complexity of medical
decision SF/L M H SF L M H L/M
Average time (minutes) 25
99304
35
99305
45
99306
10
99307
15
99308
25
99309
35
99310
30
99318
Level I II III I II III IV
Domiciliary, Rest Home (eg, Boarding Home), or Custodial Care Services and Home Care
Requires 3 components within shaded area Requires 2 onents within shaded area
History PF EPF D C C PF interval EPF interval D interval C interval
Examination PF EPF D C C PF EPF D C
Complexity of
medical decision SF L M M H SF L M M/H
Average time
(minutes)
20
Domiciliary (99324)
Home care (99341)
30
Domiciliary (99325)
Home care (99342)
45
Domiciliary (99326)
Home care (99343)
60
Domiciliary (99327)
Home care (99344)
75
Domiciliary (99328)
Home care (99345)
15
Domiciliary (99334)
Home care (99347)
25
Domiciliary (99335)
Home care (99348)
40
Domiciliary (99336)
Home care (99349)
60
Domiciliary (99337)
Home care (99350)
Level I II III IV V I II III IV
PF = Problem focused EPF = Expanded problem focused D = Detailed C = Comprehensive SF = Straightforward L = Low M = Moderate H = High
– 3 –
Establishe
dcomp
New
SOAP Note
Nicole Wertheim College of Nursing and Health Sciences – Florida International University
NG 6601L – Advanced Family Health Nursing Practice
Professor:
November 13th, 2023
Patient Age: 21-year-old male Patient
Ethnicity: African American
Clinical Setting: MSMC ED Blue Pod Patient
Status : ED patient New
Subjective Data
Chief Complaint
“Twisted Left ankle”
History of Present Illness
A 21-year-old African-American male presents to the emergency department complaining
of left ankle pain and the inability to bear weight on the left foot. Pt. states that he was playing
basketball yesterday and was “going in for a rebound when he landed on a teammate’s foot,” and
his left ankle inverted. He describes the pain as dull and, throbbing,non- radiating and currently
states the pain is a 7/10. Pt. says the pain is intensified if the leg is in a dependent position or if he
attempts to bear weight. Pain is relieved with rest, ice, elevation, and Ibuprofen 600mg; the last
dose was taken before bed last night. Pt. denies any LOC, H/A, neck pain, sore throat, cough,
SOB, CP, abdominal pain, back pain, lower extremity weakness, swelling, dysuria, hematuria,
fever, chills, rashes or unintentional weight loss. Pt. states, “I am scared I may have fractured it,
and I want an X-ray; if it’s a sprain, my team has a physical therapist I can see.” No further
complaints at this time.
Past Medical History
Patient denies past medical history
Medications
Denies any medications, supplements, or vitamins. Pt. took OTC Ibuprofen x1
dose before bed last night with minimal relief for pain relief.
Past Surgical History
Denies any past surgical history
Allergies
NKDA
Health Promotion and Maintenance
The patient is fully vaccinated for COVID-19. He has not had the seasonal flu
vaccine and is scheduled for his annual physical with this primary care provider
next month (Dec, 2023). Pt. has had his vision checked one month ago (Oct, 2023)
and wears corrective lenses to read. Immunizations are up to date, STI
screening was performed two months ago (Sep, 2023), and safe sex practices were
discussed with the patient. The patient denies the use of alternative care practices
and states he is not religious, but his mother is a very devout Christian.
Family History
Patient mother – 42 yr old- Healthy, no medical conditions
Patient Younger Sister – 12 yr old- Healthy (seasonal allergies)
Grandmother- deceased (78), CVA
Grandfather- deceased (80) MVA
Social History
The patient lives with his mother. He is the youngest child at 21 years of age,
with one sibling, who is 12 years of age. He attends college, works part-time, and
plays competitive basketball. He follows a heart healthy diet. He works out 3-5
times per week, follows a high- protein, low carb diet, and denies alcohol, tobacco
and vape use, but reports smoking marijuana occasionally.
Marital status- Single
Parental status- no children
Work history- part- time job at a sneaker shop
Financial history- Insured
Diet- Heart healthy, high protein, low carb, x3 meals/day, well hydrated/well nourished.
Exercise- Frequency (3-5x/week) competitive basketball player.
Stress management- Sports, video games, dancing.
Sleep- 6-8 hours/night
Sexual history/orientation- Heterosexual male, sexually active (x1 partner), uses protection,
screened for STIs. “In the past twelve months, how many partners have you had?” (Two) “Do
you have vaginal sex, anal sex, oral sex, anal sex?” Engages in vaginal and oral sex and utilizes
condoms. Past history of STIs? No.
Living arrangement- Lives with mother and younger sister in a gated apartment complex.
Social support- Mother, sister, basketball team, and a good circle of friends.
Travel history- In-state travel, denies out-of-state travel for the past five years.
Functional Status
The patient is fully independent with ADLs.
Cultural Background
Individuals identifying as Black or African American make up 12.5% of individuals
within the United States; when in combination with other race groups, that percentage increases
to 15% (Larson, 2022). Regarding health, healthcare, and approach to patients, it is vital to
understand the basics of the following: marginalization, discrimination, racism, and lack of
access to care are visceral issues that affect black patients far more than white counterparts. As
healthcare providers, implicit bias, although an unconscious thought process affecting our
decision-making, can significantly affect patient outcomes, treatment, patient interaction,
therapeutic options, diagnoses, and all aspects of patient interaction (Larson,2022). Today’s
presenting patient is a healthy black male, health conscious, providing an opportunity to build
rapport with healthcare providers and be further counseled regarding health screenings,
prevention, and maintenance. Early conversations regarding heart disease, hypertension, and
stroke will be beneficial in educating this patient regarding health equity and access to healthcare
screenings necessary to ensure good health. Blacks are two times more likely to pass away from
heart disease than white counterparts (Larson, 2022).
Review of Systems (Patient as Historian)
Constitutional: Patient denies chills, fatigue, excessive weight loss, or weight gain.
Head/face: Patient denies dizziness, headaches, or lightheadedness
Eyes: Patient denies any pain, redness, excessive tearing, double or blurred vision. The
patient utilizes glasses for computer use/video games/schoolwork. Last eye examination
one month ago (Oct 2023).
Ears: Patient denies ear pain, drainage, and ear ringing. Pt. has never had vertigo, ear
infections, or cerumen impactions.
Nose: Patient denies nasal stuffiness, discharge, or itching. No nosebleeds or sinus
trouble was reported.
Mouth/Throat/ Neck: Patient denies sore throat; no pain or stiffness in neck is reported.
Last dental examination: x1 yr ago with no issues reported: no mouth sores, voice
changes, or hoarseness.
Respiratory: Pt denies cough, SOB, wheezing, or painful breathing—no history of
asthma, no recent URI, or history of pneumonia.
Cardiac: No chest pain or discomfort, shortness of breath, or palpitations reported. No
swelling was reported. No sudden awakening from sleep, no difficulty breathing while
lying down. Past EKGs were reported to be normal. Yearly sports physical conducted for
competitive basketball.
GI: Pt. denies abdominal pain, indigestion, N/V/D, hematochezia, and changes in
appetite. States he has normal bowel movements with regularity.
Peripheral Vascular- Negative for leg cramps, varicose veins, calf swelling, redness or
tenderness.
GU: No dysuria or hematuria reported. No issues with bowel or bladder control were
reported. No penile discharge, scrotal swelling, or STI concern.
Musculoskeletal: Complaining of pain, tenderness, and lateral swelling to the LEFT
ankle with inability to bear weight. Decreased range of motion and bruising to the
LEFT ankle, no loss of sensation. Denies joint pain, stiffness, weakness, swelling, or
movement limitations to the right lower extremity, and no joint pain/stiffness/limitations
or loss of sensation to the upper extremities.
Skin/Integument: No rashes, lesions, or itching reported. The patient denies any skin
changes. Patient denies changes to hair or nails.
Psychiatric: No behavioral or emotional issues reported, no anxiety, depression or
suicidal ideations.
Neuro: No neurological symptoms reported. Pt. states no history of strokes, seizures,
numbness, tingling, mood changes, dizziness, vertigo, or fainting.
Endocrine: Denies any temperature intolerance, excessive sweating, no hormone
therapy, no complaints.
Hematologic/Lymphatic: No history of bleeding disorders or frequent infections,
abnormal bleeding, or bruising. No known allergies reported.
Allergic/Immunologic: no allergies, or immunologic issues to report.
Objective Data
Vital Signs
BP: Left Arm: 122/76
HR: 64
RR: 20
O2 Sat: 100% on room air
Temp: 98°F
Height: 6’2”
Weight: 180 lbs.
BMI: 23.11 (healthy)
Physical Examination
Constitutional: The patient appears his stated age, is well groomed, and is in no acute distress,
denies weight loss, night sweats or chills.
General: The patient is a 21-year-old male who appears his stated age, is well-appearing, and
has a well-nourished athletic build. No signs of pallor, cyanosis, or jaundice
noted.
He presented
to the ED and is seated in a semi-fowlers position. He is awake alert and oriented to person, time,
and place. No recent weight changes reported. Patient presents due to Left ankle pain x1 day after
a sports injury whilst playing basketball.
Head/face: Normocephalic and atraumatic. Facial expressions are appropriate. No abnormalities
noted to eyebrows, palpebral fissures, nasolabial folds, and sides of mouth. No weakness or
involuntary movements noted to facial muscles. No swelling noted. Pt. denies any facial trauma,
or pain.
Eyes: Pupils equal, round, and reactive to light. Extraocular movements are intact. The eyeballs
look moist and glossy; they are aligned normally with no protrusion or sunken appearance. No
loss of vision. Pt utilizes corrective lenses. No history of eye surgery, eye pain, photophobia,
diplopia, spots or floaters.
Ears: The ears are equal size bilaterally with no swelling or thickening. Skin is intact with no
lumps or lesions. Pinna and tragus are firm with no pain during movement. Palpation to mastoid
process is painless. No swelling, redness or discharge noted to external auditory meatus. No
redness swelling, lesions, foreign bodies or discharge noted to external canal. The tympanic
membrane is intact, shiny and translucent, no discoloration noted.
Nose: The nose is symmetric, midline proportionate to other facial features. No deformities,
asymmetry, inflammation, or skin lesions. Nostrils are patent. Nasal mucosa is a normal red
color with a smooth and moist surface. No excessive secretions, blood or purulent drainage
noted.
Mouth/Throat/ Neck: Lips are moist, no cracking or lesions noted. Oral mucosa moist, no
thrush or lesions noted. Teeth appear straight, evenly spaced, free of decay. The jaw is properly
aligned. The tongue is pink and even. Neck is supple, motion is smooth and controlled. Trachea
is midline. No drooling,or pooling of saliva noted. No cervical lymphadenopathy noted, no
posterior lymphadenopathy noted, no masses. Thyroid not palpable, no bruits. Carotid pulses 2+
and equal bilaterally.
Respiratory: Chest expansion symmetric. Breath sounds are clear to auscultation bilaterally, no
rales, rhonchi, or adventitious breath sounds. Respiratory rate is normal, and respirations are
relaxed and even.
Cardiac: S1 and S2 are normal, not diminished or accentuated, no extra sounds, no murmurs.
Capillary refill is brisk <2 seconds. Apical impulse at 5th intercostal space, left midclavicular
line. No heave or thrill. Regular rate and rhythm with no murmurs. Pt. is very athletic, HR stable
between 50-65 bpm.
GI: Flat, symmetric with no apparent masses. Skin smooth with no striae, scars, or lesions.
Bowel sounds present, no bruits. Tympany to percussion in all 4 quadrants. Abdomen soft to
palpation, no guarding, no rebound, no CVA tenderness, no organomegaly, no masses, no
tenderness. LBM this morning.
GU: No abnormalities or lesions noted.
Musculoskeletal: Unable to tandem walk due to Left ankle pain, presents with limping gait.
LEFT ANKLE: Limited ROM, tenderness to the lateral malleolus, mild swelling and
ecchymosis noted. Anterior Drawer tests positive for pain indicating pain at the Anterior
Talo-Fibular Ligament. Pt. denies tenderness to the tibia and fibula confirmed with the squeeze
test. No abnormalities to the left foot or toes, no swelling or tenderness or bruising noted at the
base of the fifth metatarsal. Pain is localized solely at the lateral malleolus. Patient is able to bare
weight fully on right foot. Joints and muscles symmetric; no swelling, masses, or deformity
noted to right lower extremity; Muscle strength—able to maintain flexion against resistance and
without tenderness. normal spinal curvature. No tenderness to palpation of right lower extremity
or upper extremities. DPA and PTA 2+ bilaterally.
Skin/Integument: Skin is brown/black, warm to touch, and dry, with no rashes or lesions noted.
Skin turgor is within normal limits, no clubbing or deformities, nail beds pink with prompt
capillary refill <2 seconds.
Psychiatric: Patient is calm with no acute mental status changes.
Neuro: Cranial nerves II-XII grossly intact. No focal neurological deficits or changes
appreciated. light touch, vibration intact.
Mental Status: Age-appropriate behavior and interaction observed.
Motor Strength: Gross and fine motor skills appear normal. 5/5, +5 , DTR 2+ throughout.
Sensory: No sensory abnormalities observed.
Hematologic/Lymphatic/Immunologic: No abnormalities noted on exam.
Assessment
Primary Diagnosis – Left Ankle Sprain/ Unspecified Ligament Injury of the Left Ankle
(S.93.402.A)
** Based on physical exam and inversion injury, strong suspicion of Talo-Fibular Ligament involvement.
Differential Diagnosis
Ankle Fracture (S82)
Stress Fracture (M84.372A)
Tendon Dislocation or Rupture (S93.05XA)
Ligamentous Laxity syndrome/fathers medical history unknown) (M24.2)
Risk Factors
Competitive basketball player, low top sneakers worn the day of injury.
Plan
Diagnostics: Based on the Ottawa Ankle Rule, this patient presents with left ankle lateral
malleolar pain, with bony tenderness to the tip of the lateral malleolus and an inability to bare
weight or take four steps after the injury and within the emergency department. Given the patients
presentation, an ankle x-ray is indicated (Hwang,2023). The clinical pearl of Ottawa
Rules are the exclusion of fifth metatarsal or foot pain. This patient does not have fifth metatarsal
or foot pain, indicating that a Left ankle 3 view x-ray is appropriate in this case presentation.
Our patients x-ray was negative, physical exam was indicative of a tendon injury. Requiring
further evaluation for sprain grading and treatment.
Pharmacologic management: Ibuprofen 600mg, every 8 hours as needed for pain OR,
Acetaminophen 650 mg every 4-6 hours for pain , there has been no research to show superiority
over a particular NSAID. The patient is a healthy male and has selected Ibuprofen prior to arrival
(Maughan & Jackson, 2023). Ibuprofen 600mg given in the ED prior to x-ray, ICE pack applied
in ED.
Non-Pharmacologic management: Air Cast application, crutches, RICE : Rest, Ice,
Compression, and Elevation.
• Protection and compression with the Air Cast
• Rest with limited movement and no weight bearing and use of crutches
• Cryotherapy, 20 minutes every 2-3 hours while awake for the first 72 hours
• Elevation- to alleviate swelling, above the level of the heart.
Patient Education:
1. Rest ankle, ensure proper use of crutches, and follow RICE protocol with barrier between
skin and cryotherapy (Maughan & Jackson, 2023).
2. Given competitive sports involvement follow up with orthopedic and physical therapy
after orthopedic clearance. It is shown that patients that seek physical therapy for ankle
sprain recovery are less likely to have recurrent or chronic ankle sprains (Duwairi, 2023).
Referrals: Orthopedic Surgeon and Physical Therapy
Follow up: Follow up with PCP or return to the ED if worsening or no improvement within 7
days.
Analysis
Within this case, a very healthy and athletic 21-year-old male presented with left ankle
pain, and stated that he had an inversion injury the day prior whilst playing basketball. He denied
any significant past medical history, surgical history or social history significant to this case. The
patient denied any previous sports injuries or ankle/foot/leg injuries previously. Subjectively he
reported classic signs and symptoms of a Grade 1-2 ankle sprain such as moderate pain,
swelling, tenderness and ecchymosis with moderate joint instability and restriction of range of
motion and inability to bare weight .Lateral sprains due to inversion injuries are responsible for
70-90% of all sprains (Maughan & Jackson, 2023).
On physical exam, he presents with lateral swelling over the malleolus, bony tenderness
to the tip of the lateral malleolus and an inability to bare weight or take four steps after the injury
and within the emergency department. Ecchymosis over the malleolus, and a non-tender tibia,
fibula, and left foot. The patient had a positive anterior drawer test, and a limping gait on arrival.
Initial goals for this patient are to control pain, reduce swelling, and maintain range of
motion before gradually introducing exercise (Maughan & Jackson, 2023). PRICE: an acronym
similar to RICE just adding protection is important in the acute stages and is essential when
including the lateral malleolus for the first three days after injury. If the sprain is a Grade 1 or 2,
range of motion exercises such as plantar flexion, dorsiflexion, and foot circles or the alphabet
can be achieved passively after the acute phase has subsided (Duwairi, 2023). Functional
rehabilitation has been shown to be far superior when compared to complete immobilization,
thus early light activity, and physical therapy consults are important for patients (Maughan &
Jackson, 2023). Ironically in any sprain grade immobilization was not completely preferred.
NSAIDS, should be given as needed for pain and non-pharmacological options such as
PRICE should be utilized to ensure protection, rest, ice, compression and elevation are achieved
in the acute phase. The patient is a competitive athlete and should be referred and evaluated by
an orthopedic surgeon and physical therapist, and be sure to return to the ED or PCP should
symptoms not improve. Very interestingly in cadaver study of human anterior talofibular
ligaments, 50% of humans have a single banded ligament, where 50% have a double banded
ligament. Making the strength of the ligament stronger with double-banded ligaments (Sarcon et
al., 2019). The phrase “I am prone to ankle sprains”, is anatomically true. The Ottawa Rules help
practitioners make better decisions when treating ankle and knee injuries guiding our diagnostic
decisions. In this case, X-ray decisions with a 3-view x-ray (negative results), ice, compression,
rest and elevation, the patient was well managed.
References
Duwairi, M. Q. (2023). Acute ankle sprain. Saudi medical journal, 19(3), 329–331.
Hwang, C. (2023). Ottawa ankle rule. MDCALC.com. Retrieved 2023, from
https://www.mdcalc.com/calc/1670/ottawa-ankle-rule
Larson, J. (2022). Cultural Considerations in Working with Black and African American Youth.
Child and Adolescent Psychiatric Clinics of North America, 733–744.
Maughan, K. L., & Jackson, J. (2023). Ankle sprain in adults: Evaluation and diagnosis (M.
Gammons, F. G. O’Connor, & J. Grayzel, Eds.). UpToDate. Retrieved November 16,
2023, from https://www.uptodate.com/contents/ankle-sprain-in-adults-evaluation-and-
diagnosis?search=ankle%20sprain%26source=search_result&selectedTitle=1~53&usage
_type=default&display_rank=1
Sarcon, A. K., Heyrani, N., Giza, E., & Kreulen, C. (2019). Lateral ankle sprain and chronic
ankle instability. Foot & Ankle Orthopaedics, 4(2), 247301141984693.
https://doi.org/10.1177/2473011419846938
https://www.mdcalc.com/calc/1670/ottawa-ankle-rule
https://www.uptodate.com/contents/ankle-sprain-in-adults-evaluation-and-diagnosis?search=ankle%20sprain%26source%3Dsearch_result&selectedTitle=1%7E53&usage_type=default&display_rank=1
https://www.uptodate.com/contents/ankle-sprain-in-adults-evaluation-and-diagnosis?search=ankle%20sprain%26source%3Dsearch_result&selectedTitle=1%7E53&usage_type=default&display_rank=1
https://www.uptodate.com/contents/ankle-sprain-in-adults-evaluation-and-diagnosis?search=ankle%20sprain%26source%3Dsearch_result&selectedTitle=1%7E53&usage_type=default&display_rank=1
https://doi.org/10.1177/2473011419846938
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