Physiotherapist-Vorlage
Adult Biomechanical/Feet Ax
Eine professionelle Physiotherapist-Vorlage für medizinisches Fachpersonal.
Über diese Vorlage
Looking for a detailed record of your physiotherapy assessment? This Adult Biomechanical/Feet Ax template is designed for physiotherapists to thoroughly document foot and lower limb assessments. It covers subjective findings, objective measures like posture and gait analysis, and a comprehensive plan. This template helps you capture everything from patient goals to treatment plans, ensuring a complete record. Heidi's AI scribe can populate this template from your clinical notes, saving you time and improving documentation accuracy. Get a clear picture of your patient's condition and progress with this essential tool.
Vorlagenvorschau
Subjective:
Patient presents today with a chief complaint of left foot pain, which started approximately 6 weeks ago after increasing running mileage. The pain is described as a dull ache, located on the plantar aspect of the foot. The patient reports that the pain is gradually worsening and is now affecting their ability to run and walk comfortably. They have tried rest and ice, which provided temporary relief, but the pain returns with activity. The patient denies any specific mechanism of injury.
Patient valued outcomes (PVOs):
Patient's goals are to return to running without pain and to be able to walk comfortably for daily activities.
VAS:
VAS score is currently 6/10.
Aggravated by:
Aggravating factors include running, prolonged standing, and walking on uneven surfaces.
Eased by:
Easing factors include rest and ice.
Scans:
Patient had an X-ray of the left foot 2 weeks ago, which was unremarkable.
PMH:
Patient has no significant past medical history.
Social Hx:
Patient is a non-smoker and drinks alcohol socially. They are employed as a software engineer and have a sedentary lifestyle.
Objective:
Posture:
Patient demonstrates a mild pes planus on the left foot.
Gait:
Patient exhibits a slight antalgic gait on the left side.
Feet:
Palpation reveals tenderness over the plantar fascia on the left foot. There is no obvious swelling or deformity.
Inv/Ev (Inversion/Eversion):
Full range of motion, pain-free.
Squat:
Patient can perform a squat, but reports pain in the left foot.
Unilateral Squat:
Patient unable to perform unilateral squat on the left side due to pain.
Jump:
Patient reports pain on landing.
Hop:
Patient unable to hop on left foot.
Up Toes:
Patient reports pain on the left foot.
Flexibility:
Reduced dorsiflexion on the left ankle.
Strength:
Weakness noted in the intrinsic foot muscles on the left side.
Knees:
Alignment normal.
Shin:
No tenderness to palpation.
Calf:
No tenderness to palpation.
IMPRESSION:
Plantar fasciitis, left foot.
PLAN:
Advise patient to rest from aggravating activities. Provide education on plantar fasciitis and activity modification. Commence with soft tissue massage to the calf and plantar fascia. Prescribe a home exercise programme including stretching and strengthening exercises. Review in one week.
TREATMENT:
Soft tissue massage to the calf and plantar fascia. Taping to support the arch.
HEP (Home Exercise Programme):
Prescribed stretching exercises for the plantar fascia and calf muscles. Prescribed strengthening exercises for the intrinsic foot muscles.
ADVICE:
Advised patient to avoid activities that aggravate the pain. Advised the patient to wear supportive footwear. Educated patient on the importance of compliance with the home exercise programme.
NEXT DAY:
Review the patient's progress and adjust the treatment plan as needed.
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