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I HUMAN CASE STUDY RONNIE LIU 14 YEAR OLD REASON FOR ENCOUNTER PAIN AND
SWELLING IN RIGHT ANKLE COMPLETE HISTORY, PHYSICAL, ASSESSMENT, PROBLEM
STATEMENT, DIAGNOSES AND SOAP NOTES
Patient Information
Name: Ronnie Liu Age: 14 years old Height: 175 cm
Weight: 63.6 kg
Chief Complaint
Pain and swelling in the right ankle
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History interview for Ronnie Liu
Chief Complaint:
1. Can you describe the pain in your ankle? (sharp, dull, constant, intermittent)
2. How long have you been experiencing pain in your right ankle?
3. Can you rate your pain on a scale from 1 to 10?
History of Present Illness:
4. What were you doing when the pain and swelling started?
5. Did you hear or feel a pop at the time of the injury?
6. Have you noticed any bruising or discoloration around the ankle?
7. Are you able to bear weight on your right ankle? If not, how are you moving around?
8. What have you done to manage the pain and swelling so far (e.g., ice, rest, medication)?
Past Medical History:
9. Have you had any previous injuries to your right ankle or other joints?
10. Do you have any chronic health conditions?
11. Have you had any recent illnesses or infections?
Hospitalizations/Surgeries:
12. Have you ever been hospitalized for any reason?
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13. Have you had any surgeries in the past?
Preventive Health: 14. Are your vaccinations up to date?
15. Do you get regular check-ups with your doctor?
Medications: 16. Are you currently taking any medications, including over-the-counter drugs or
supplements?
17. Have you taken any pain medications for this injury? If so, what and how often? Allergies:
18. Do you have any allergies to medications, foods, or other substances? Family History:
19. Is there any family history of joint or musculoskeletal problems?
20. Do any of your family members have chronic health conditions?
Social History:
21. Do you participate in any sports or physical activities? Which ones and how often?
22. Do you smoke, drink alcohol, or use recreational drugs?
23. What is your living situation like? Do you have support at home?
Review of Systems:
24. Do you have any other symptoms such as fever, chills, or general fatigue?
25. Have you had any headaches, vision changes, or ear/nose/throat problems?
26. Do you have any chest pain, palpitations, or known heart issues?
27. Are you experiencing any shortness of breath, cough, or wheezing?
28. Have you had any abdominal pain, nausea, or changes in bowel habits?
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I HUMAN CASE STUDY RONNIE LIU 14 YEAR OLD REASON FOR ENCOUNTER PAIN AND
SWELLING IN RIGHT ANKLE COMPLETE HISTORY, PHYSICAL, ASSESSMENT, PROBLEM
STATEMENT, DIAGNOSES AND SOAP NOTES
Patient Information
Name: Ronnie Liu Age: 14 years old Height: 175 cm
Weight: 63.6 kg
Chief Complaint
Pain and swelling in the right ankle
1
,Page 2 of 20
History interview for Ronnie Liu
Chief Complaint:
1. Can you describe the pain in your ankle? (sharp, dull, constant, intermittent)
2. How long have you been experiencing pain in your right ankle?
3. Can you rate your pain on a scale from 1 to 10?
History of Present Illness:
4. What were you doing when the pain and swelling started?
5. Did you hear or feel a pop at the time of the injury?
6. Have you noticed any bruising or discoloration around the ankle?
7. Are you able to bear weight on your right ankle? If not, how are you moving around?
8. What have you done to manage the pain and swelling so far (e.g., ice, rest, medication)?
Past Medical History:
9. Have you had any previous injuries to your right ankle or other joints?
10. Do you have any chronic health conditions?
11. Have you had any recent illnesses or infections?
Hospitalizations/Surgeries:
12. Have you ever been hospitalized for any reason?
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13. Have you had any surgeries in the past?
Preventive Health: 14. Are your vaccinations up to date?
15. Do you get regular check-ups with your doctor?
Medications: 16. Are you currently taking any medications, including over-the-counter drugs or
supplements?
17. Have you taken any pain medications for this injury? If so, what and how often? Allergies:
18. Do you have any allergies to medications, foods, or other substances? Family History:
19. Is there any family history of joint or musculoskeletal problems?
20. Do any of your family members have chronic health conditions?
Social History:
21. Do you participate in any sports or physical activities? Which ones and how often?
22. Do you smoke, drink alcohol, or use recreational drugs?
23. What is your living situation like? Do you have support at home?
Review of Systems:
24. Do you have any other symptoms such as fever, chills, or general fatigue?
25. Have you had any headaches, vision changes, or ear/nose/throat problems?
26. Do you have any chest pain, palpitations, or known heart issues?
27. Are you experiencing any shortness of breath, cough, or wheezing?
28. Have you had any abdominal pain, nausea, or changes in bowel habits?
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