SOAP Note

**Progress Note – John Smith, DOB: 1978/03/15** 2024/11/01 **Subjective:** - Reason for consultation: Patient presents with pain in the right foot. - History of presenting complaint: The patient reports a sharp pain in the plantar aspect of the right foot, which started approximately 2 weeks ago. The pain is worse in the morning and after prolonged standing. There is no history of trauma. The pain is aggravated by walking and relieved by rest. - Physiotherapy progress: Patient has not had physiotherapy. - Symptom evolution and general progress since last visit: No previous visits. **Objective:** - **Vascular:** Pedal pulses are palpable bilaterally. No edema or varicose veins noted. Capillary refill is <2 seconds. - **Musculoskeletal:** Inspection reveals no obvious deformity. Palpation elicits tenderness over the plantar fascia. Range of motion is limited due to pain. Strength is normal. No joint instability is noted. - **Neurological:** Sensory and motor function intact. No paresthesia noted. - **Dermatological:** No skin or nail changes observed. - Surgical wound appearance: N/A - Investigation results: X-rays of the right foot were taken, showing no fracture. **Assessment & Plan:** 1. Plantar Fasciitis - Diagnosis and rationale: Based on subjective complaints of plantar foot pain, worse in the morning and after prolonged standing, and tenderness on palpation of the plantar fascia, and negative X-rays. - Planned investigations: None. - Planned surgical treatment: None. - Non-surgical treatment plan: Advised rest, ice, stretching exercises, and over-the-counter pain relief. Consider orthotics if symptoms persist. - Referrals: Consider referral to physiotherapy if symptoms do not improve. "Additional Podiatric Issues or Conditions:" - None **Additional Notes:** - Patient education provided: Explained the condition of plantar fasciitis, its causes, and the importance of rest, ice, and stretching exercises. Discussed the potential need for orthotics. - Patient or family concerns addressed: Patient expressed concern about the pain and its impact on daily activities. Reassured the patient that the condition is treatable and provided a plan for management. - Informed consent discussion: N/A - Material risks discussed – version 1: N/A - Material risks discussed – version 2: N/A - Material risks discussed – version 3: N/A **ICD code:** - M72.2 **CPT code:** - 99203