,PRESENTING COMPLAINT:
Patient reports ongoing pain in the plantar aspect of the left foot, especially in the morning and after prolonged standing. The pain has been present for approximately 6 weeks and is gradually worsening.
,Footwear and orthotics:
Patient wears Asics Gel-Kayano trainers, model year 2023, primarily for running and daily activities. The upper is made of breathable mesh and synthetic materials. Fastening is via laces.
Practitioner noted mild wear on the lateral aspect of the left shoe, suggesting possible overpronation.
Patient currently uses off-the-shelf arch supports in their trainers.
,Patient goals:
Patient aims to reduce foot pain, improve mobility, and return to running without discomfort.
,ASSESSMENT OF CONDITION:
POP: Tenderness on palpation of the plantar fascia insertion point and medial calcaneal tubercle.
Assessment revealed reduced dorsiflexion in the left ankle.
Observations: Mild pes planus noted bilaterally.
,Gait:
Patient demonstrates a mild overpronated gait pattern on the left side.
,TREATMENT OF CONDITION:
Treatment included massage to the plantar fascia and calf muscles.
Strapping applied to support the medial arch using rigid sports tape.
Advice given to patient included rest, ice application, and activity modification.
,Prescribed exercises:
Prescribed calf stretches, holding for 30 seconds, repeated 3 times, twice daily.
Patient should feel a stretch in the calf muscle.
,PLAN:
Patient to return in 2 weeks for review.
Review plantar fascia pain and gait pattern.
Patient to be provided with a handout on plantar fasciitis management.
Date: 1 November 2024
PRESENTING COMPLAINT:
[describe presenting complaint] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Footwear and orthotics:
[describe current and most regularly worn shoes, including brand, model, materials of upper, fastening details, and activity use] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[describe remarks made by practitioner regarding existing footwear, including wear pattern, suitability, and condition] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[describe current or previous use of orthotics, including whether custom made, off-the-shelf, or adjusted, age of device, current use, and activities or footwear used in] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Patient goals:
[describe patient goals for seeking podiatric treatment] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
ASSESSMENT OF CONDITION:
[list areas of pain or tenderness on palpation as POP or TOP] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[describe results of assessments undertaken during today's consultation, including reference to previous results if discussed] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[list observations of anatomical or physical structures] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Gait:
[describe gait observations made by practitioner, including any pain or sensations experienced by patient during gait assessment] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
TREATMENT OF CONDITION:
[list treatments performed at today's consultation, such as massage, dry needling, shockwave, strapping, padding, heel wedges or heel raises] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[describe shockwave treatment, including pulses administered, intensity level, frequency level, size of head used, and structure treated] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[describe strapping, including type of tape used, structures applied to, and technique used] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[describe dry needling, including structure needled, number of needles used, and symptoms experienced by patient] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[describe padding, including shape, application method, and placement] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[list instructions provided to patient about removal of padding or strapping/taping] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[list instructions provided about gradual wearing in of orthotic devices] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[list advice given to patient such as rest, analgesia, footwear or activity modification, or other education] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[list other podiatric care provided at today's consultation such as nail or skin care] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[note whether custom foot orthotics were recommended and whether they will be ordered now or considered at future consultations, including specific prescription requirements] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Prescribed exercises:
[list prescribed exercises, recommended reps, frequency, goal reps, and specific instructions] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[list information provided about what the patient should feel during or after exercises] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[mention whether specific equipment has been recommended or provided] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[note whether exercises are to be increased or changed, and when] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
PLAN:
[list when the patient is required to return for their next treatment] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[list issues to be reviewed or addressed at next consultation] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[list details to be communicated to or by the patient after their appointment] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
(For each section, only include if explicitly mentioned in transcript or context, else omit section entirely. Never come up with your own patient details, assessment, plan, interventions, evaluation, or next steps—use only the transcript, contextual notes, or clinical note as reference for all information. If any information related to a placeholder has not been explicitly mentioned, do not state that in the output; simply leave the relevant placeholder or section out entirely. Use as many lines, paragraphs, or bullet points as needed to capture all relevant information from the transcript.)
