Aquifer Family Medicine Case# 4
Name:
United States University
FNP 593: Primary Health of Acute Clients/Families Across the Lifespan
Dr. Tiffany Glass
04/28/2025
, Aquifer Family Medicine Case# 4
The patient is a 19-year-old female who exhibits sudden right ankle pain following an inversion
accident. She was able to bear weight on the joint soon following the accident; nevertheless, she
presently requires assistance to walk in the office. Mild swelling is shown with no pain with probing of
the medial malleolar region; however, soreness is noted over the lateral malleolus of the right foot, with
no tenderness on the dorsal or lateral aspects of the foot. The primary diagnosis is
Anterior Talofibular Ligament (ATFL) Sprain (Ankle inversion injury) ICD-10 Code: S93.4X1A – Sprain of
anterior talofibular ligament of right ankle, initial encounter. The patient’s presentation following an
inversion injury with swelling, tenderness over the lateral malleolus, and difficulty walking suggests an
ankle sprain involving the lateral ligaments, most notably the anterior talofibular ligament, which is the
most injured in inversion injuries. The ability to bear weight with assistance indicates a mild to
moderate sprain rather than a fracture or complete ligament rupture (Garrick et al., 2021).
Differential Diagnoses
Lateral Malleolar Fracture - ICD-10 Code: S82.62XA
Fracture of lateral malleolus, initial encounter for closed fracture. Fractures typically
present with localized, significant tenderness over the malleolar area, often with deformity or
crepitus. In this case, the patient exhibits only mild swelling and tenderness without deformity or
bony step-off. Recent evidence supports that clinical sign like inability to bear weight and
specific tenderness over the malleolus are key indicators for radiographs (Garrick et al., 2021).
The absence of these signs reduces the likelihood of a fracture, aligning with Ottawa
Name:
United States University
FNP 593: Primary Health of Acute Clients/Families Across the Lifespan
Dr. Tiffany Glass
04/28/2025
, Aquifer Family Medicine Case# 4
The patient is a 19-year-old female who exhibits sudden right ankle pain following an inversion
accident. She was able to bear weight on the joint soon following the accident; nevertheless, she
presently requires assistance to walk in the office. Mild swelling is shown with no pain with probing of
the medial malleolar region; however, soreness is noted over the lateral malleolus of the right foot, with
no tenderness on the dorsal or lateral aspects of the foot. The primary diagnosis is
Anterior Talofibular Ligament (ATFL) Sprain (Ankle inversion injury) ICD-10 Code: S93.4X1A – Sprain of
anterior talofibular ligament of right ankle, initial encounter. The patient’s presentation following an
inversion injury with swelling, tenderness over the lateral malleolus, and difficulty walking suggests an
ankle sprain involving the lateral ligaments, most notably the anterior talofibular ligament, which is the
most injured in inversion injuries. The ability to bear weight with assistance indicates a mild to
moderate sprain rather than a fracture or complete ligament rupture (Garrick et al., 2021).
Differential Diagnoses
Lateral Malleolar Fracture - ICD-10 Code: S82.62XA
Fracture of lateral malleolus, initial encounter for closed fracture. Fractures typically
present with localized, significant tenderness over the malleolar area, often with deformity or
crepitus. In this case, the patient exhibits only mild swelling and tenderness without deformity or
bony step-off. Recent evidence supports that clinical sign like inability to bear weight and
specific tenderness over the malleolus are key indicators for radiographs (Garrick et al., 2021).
The absence of these signs reduces the likelihood of a fracture, aligning with Ottawa
