NURS 5220 Mixed-up SOAP Note Assignment|
2026 Latest Update with Complete Solution -
University of Texas, Arlington
Mixed-up SOAP Note
The University of Texas at Arlington College of Nursing
In partial fulfillment of the requirements of
NURS 5220 Advanced Health Assessment Across the Lifespan
Toshia McKeon, MSN, APRN, CPNP-PC
September 5, 2025
, What type of history will you obtain for this visit?
A complete history will be obtained since this is A.J.'s first visit to the primary care
office. If the patient would have presented to urgent care or emergency department a problem or
focused history would be obtained since the chief concern is an acute issue (Ball et al, 2019, p.
21).
What additional history would you obtain from the family that is significant to A.J.'s
situation?
See yellow highlighted italicized areas within the SOAP note form
Practice using clinical reasoning and list possible diagnoses for A.J. based on the subjective
information provided: Medical Diagnosis (2)?
1) Lateral collateral ligament (LCL) Sprain
2) Muscle Strain
ICD 10 codes?
1) Code S83.422A- Sprain of lateral collateral ligament of left knee, initial encounter
(Sprain of lateral, 2020).
2) Code S86.912A - Strain of unspecified muscle(s) and tendon(s) at lower leg level, left
leg, initial encounter (Strain of unspecified, 2020)
Provide pathophysiology?
1) Sprain of lateral collateral ligament - The ligament plays an important role in the
perception of movement and passive stabilization of the joint. A ligament sprain is an
injury to the collagen that connects two or more bones to a joint. A ligament sprain is
usually caused by the fibers being stretched beyond their normal range of motion
(Ligament Sprain, 2020). The LCL connects the lateral epicondyle of the femur and the
2026 Latest Update with Complete Solution -
University of Texas, Arlington
Mixed-up SOAP Note
The University of Texas at Arlington College of Nursing
In partial fulfillment of the requirements of
NURS 5220 Advanced Health Assessment Across the Lifespan
Toshia McKeon, MSN, APRN, CPNP-PC
September 5, 2025
, What type of history will you obtain for this visit?
A complete history will be obtained since this is A.J.'s first visit to the primary care
office. If the patient would have presented to urgent care or emergency department a problem or
focused history would be obtained since the chief concern is an acute issue (Ball et al, 2019, p.
21).
What additional history would you obtain from the family that is significant to A.J.'s
situation?
See yellow highlighted italicized areas within the SOAP note form
Practice using clinical reasoning and list possible diagnoses for A.J. based on the subjective
information provided: Medical Diagnosis (2)?
1) Lateral collateral ligament (LCL) Sprain
2) Muscle Strain
ICD 10 codes?
1) Code S83.422A- Sprain of lateral collateral ligament of left knee, initial encounter
(Sprain of lateral, 2020).
2) Code S86.912A - Strain of unspecified muscle(s) and tendon(s) at lower leg level, left
leg, initial encounter (Strain of unspecified, 2020)
Provide pathophysiology?
1) Sprain of lateral collateral ligament - The ligament plays an important role in the
perception of movement and passive stabilization of the joint. A ligament sprain is an
injury to the collagen that connects two or more bones to a joint. A ligament sprain is
usually caused by the fibers being stretched beyond their normal range of motion
(Ligament Sprain, 2020). The LCL connects the lateral epicondyle of the femur and the
