Routine Podiatry Template

Subjective: Patient presents today with a chief complaint of increased pain in the left foot, specifically in the plantar region. The patient reports that the pain has been worsening over the past two weeks, especially after prolonged standing or walking. They deny any recent injury or trauma. The patient reports that they have been managing the pain with over-the-counter ibuprofen, which provides some relief. They also report a history of plantar fasciitis, which was previously treated with physical therapy. Objective: * General appearance: Appears comfortable, able to ambulate without assistance. * Vital signs: Blood pressure 130/80 mmHg, heart rate 78 bpm, respiratory rate 16 breaths/min, temperature 37°C. * Dermatologic findings: * Mild erythema and tenderness to palpation along the plantar fascia of the left foot. * No open ulcers or calluses noted. * No deformities. * Vascular assessment: * Pulses: Dorsalis pedis and posterior tibial pulses palpable bilaterally, 2+. * Capillary refill: <2 seconds bilaterally. * Neurological assessment: * Monofilament test: Intact sensation to 5.07 monofilament bilaterally. * Vibration perception: Intact to 128 Hz tuning fork bilaterally. * Reflexes: 2+ patellar and Achilles reflexes bilaterally. * Musculoskeletal assessment: * Limited dorsiflexion of the left foot. * Tenderness to palpation along the plantar fascia. Assessment: * Diagnosis: Plantar fasciitis, left foot (M72.2) * Differential diagnoses: * Stress fracture * Tarsal tunnel syndrome Plan: Patient was advised to continue with ibuprofen as needed for pain management. They were instructed to apply ice to the affected area for 15-20 minutes, 2-3 times per day. The patient was also advised to stretch the plantar fascia and Achilles tendon regularly. The patient was provided with information on proper footwear and the importance of avoiding activities that exacerbate the pain. A referral to physical therapy was made for further evaluation and treatment, including stretching exercises and possible orthotic intervention. The patient was educated on the importance of weight management and its impact on plantar fasciitis. The patient was advised to follow up in 4 weeks or sooner if symptoms worsen. Follow-up appointments and referrals to specialists: * Follow-up appointment in 4 weeks. * Referral to physical therapy. Patient education and counselling provided: * Provided education on plantar fasciitis, including causes, symptoms, and treatment options. * Counseled on proper footwear and activity modification. * Reviewed stretching exercises. Date: 1 November 2024