Patient presents with complaints of left ankle pain and swelling following a (mechanism of injury - e.g., fall, twisting injury).  Onset of symptoms occurred (timeframe - e.g., immediately, several hours ago).  Patient reports (severity of pain - e.g., mild, moderate, severe) pain exacerbated by weight-bearing and palpation.  Associated symptoms may include ecchymosis, deformity, inability to bear weight, and limited range of motion.  Physical examination reveals (objective findings - e.g., tenderness to palpation over the lateral malleolus, edema, crepitus).  Neurovascular status of the left foot is intact.  Radiographic imaging of the left ankle is indicated to evaluate for fracture.  Preliminary diagnosis of left ankle fracture unspecified is made, pending radiographic confirmation.  Differential diagnoses include ankle sprain, soft tissue injury, and tendon rupture.  Treatment plan includes pain management with analgesics, immobilization with a splint or brace, elevation, ice, and referral to orthopedics for definitive management.  ICD-10 code S92.30XA is considered pending radiographic findings.  Return to clinic scheduled in (timeframe - e.g., one week) for follow-up and further evaluation.  Patient education provided regarding activity modification, pain management, and potential complications.  Patient verbalized understanding of instructions.