Patient presents with complaints of ankle pain and swelling following a (mechanism of injury, e.g., twisting injury, fall).  On examination, there is tenderness to palpation over the posterior malleolus, ecchymosis, and edema.  Range of motion is limited due to pain.  Weight-bearing status is (weight-bearing, non-weight-bearing, partial weight-bearing) as tolerated.  Neurovascular examination reveals intact distal pulses and sensation.  Radiographic imaging (X-ray, CT scan) of the ankle confirms a posterior malleolus fracture.  The fracture is classified as (e.g., Weber type B, Maisonneuve fracture) with (describe displacement, comminution, intra-articular involvement).  Diagnosis: Posterior malleolus fracture.  Differential diagnoses considered include ankle sprain, talar fracture, and fibular fracture.  Treatment plan includes (conservative management with immobilization, surgical intervention with open reduction internal fixation ORIF, closed reduction percutaneous pinning CRPP).  Patient education provided regarding pain management, RICE protocol (rest, ice, compression, elevation), and follow-up care.  Referral to orthopedics or podiatry may be necessary depending on fracture complexity.  ICD-10 code S82.5 assigned.  CPT codes for procedures performed will be documented separately.  Prognosis is generally good with appropriate treatment, although complications such as post-traumatic arthritis, malunion, nonunion, and complex regional pain syndrome CRPS are possible.  Follow-up scheduled in (duration) for repeat radiographic evaluation and clinical assessment.