Subjective:
67-year-old female.
Patient presents today with a chief complaint of pain in her left foot, specifically in the area of the plantar fascia. She reports the pain has been worsening over the past three months, especially in the morning. She denies any recent injury.
- Hypertension
- Hyperlipidemia
- Osteoarthritis
- Lisinopril 20mg daily
- Atorvastatin 40mg daily
- Ibuprofen 200mg as needed for pain
- Non-smoker. Drinks alcohol occasionally.
Objective:
**Vascular:**
- Pedal pulses are 2+ bilaterally.
- Capillary refill is less than 2 seconds bilaterally.
- No varicose veins noted.
**Neurological:**
- Protective sensation intact to light touch and monofilament testing bilaterally.
**Dermatological:**
- Skin is dry with mild scaling. Toenails are thickened and discolored. Pain to palpation of the plantar aspect of the left foot.
- No open lesions, edema, or erythema noted.
**Epidermal skin lesions:**
- Lesion on the plantar aspect of the left foot, measuring 1.5 cm.
**Musculoskeletal:**
- No deformities noted.
- Pain with palpation of the plantar fascia of the left foot.
Plan:
Patient evaluated. Non-surgical and surgical treatment options were discussed. Past medical history, any recent changes, orders, medications, and prescriptions were reviewed.
Plantar Fasciitis
- Instructed to stretch the plantar fascia several times a day.
- Instructed to ice the affected area for 15 minutes, 2-3 times a day.
- Rx for custom orthotics.
- Rx for Ibuprofen 200mg as needed for pain.
Date: 1 November 2024
Subjective:
[Patient age and gender] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit section entirely. Write as sentence.)
[Describe current issues, reasons for visit, and history of presenting complaints] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit section entirely. Write in paragraph format.)
- [Describe past medical history, including previous surgeries] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit section entirely. Write as list.)
- [Mention medications and herbal supplements currently taken, including dose, frequency, etc. for each] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit section entirely. Write as list.)
- [Describe social history] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit section entirely. Write as list.)
Objective:
**Vascular:**
- [Describe pedal pulses] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit section entirely. Write as sentence.)
- [Describe capillary refill] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit section entirely. Write as sentence.)
- [Describe varicose veins] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit section entirely. Write as sentence.)
**Neurological:**
- [Describe protective sensation] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit section entirely. Write as sentence.)
**Dermatological:**
- [Describe skin condition, nail appearance, and nail pain to palpation] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit section entirely. Write as sentence.)
- [Describe any open lesions, edema, erythema, or clinical signs of soft tissue infection] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit section entirely. Write as sentence.)
**Epidermal skin lesions:**
- [List all lesion locations and sizes] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit section entirely. Write each lesion on a new line.)
**Musculoskeletal:**
- [Describe deformities] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit section entirely. Write as sentence.)
- [Describe pain with palpation or range of motion of joints or bones] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit section entirely. Write as sentence.)
Plan:
Patient evaluated. Non-surgical and surgical treatment options were discussed.
Past medical history, any recent changes, orders, medications, and prescriptions were reviewed.
[Document each diagnosis mentioned, with associated treatment or follow-up plan underneath] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit section entirely. Use as many lines, paragraphs or bullet points as needed. Separate each diagnosis with an empty line.)
- [List treatment or intervention associated with the diagnosis] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit section entirely. Prefix each treatment with a dash.)
- [List Rx for shoes, orthotics, braces, and referral to pedorthist] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit section entirely. Replace provider names with "pedorthist". Write as list.)
- [List Rx medications and herbal supplements prescribed at the visit, including dose and frequency] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit section entirely. Write each one as a separate list item.)
(Never come up with your own patient details, interventions, evaluation, and plan for continuing care – use only the transcript, contextual notes or clinical note as a reference for the information included in your note. If any information related to a placeholder has not been explicitly mentioned in the transcript, contextual notes or clinical note, you must not state the information has not been explicitly mentioned in your output, just leave the relevant placeholder or omit the placeholder completely. Use as many lines, paragraphs or bullet points, depending on the format, as needed to capture all the relevant information from the transcript. Replace “recommended” with “instructed”. Replace “prescribed” with “Rx” for medications and devices. Replace “callus” with “lesion”. Do not include any results discussed or physicals done in the Objective section — they belong in the Plan. The Objective section should reflect only what the patient reports, not the doctor’s observations.)
