PRESENTING COMPLAINT:
Patient presents with a chief complaint of right heel pain.
- Chief complaint: Right heel pain.
- Mechanism of injury: Patient reports the pain started gradually, with no specific injury.
- Date of onset or duration of injury: Pain started approximately 3 weeks ago.
- Pain presentation, when pain occurs, type of pain, how long it lasts, specific movements that induce it, pain patterns recognised: Pain is worse in the morning and after periods of rest. It is a sharp, stabbing pain. Pain lasts for approximately 30 minutes after getting out of bed. Walking and running exacerbate the pain. No specific pain patterns recognised.
- Aggravating factors such as type of activity, footwear, ground and floor surfaces, inclines or declines, specific foot or limb postures: Aggravating factors include running on hard surfaces and wearing flat shoes.
- Alleviating factors such as rest, medications, change in footwear, modification of activity, professional treatment, at home treatment: Rest and stretching provide some relief.
- List previously administered treatment for this specific condition, when it was undertaken, who administered it, and whether it had any effect on the condition: Patient has been using over-the-counter pain relievers with minimal effect.
History of injury:
- Previous injuries acquired, same or different to current complaint, and when acquired: No previous injuries.
- Previous symptoms or pain in the feet or lower limbs: Occasional mild arch pain in the past.
Activity levels:
- List current sport, exercise, or activity undertaken. Include duration, frequency, intensity. Note whether patient believes this activity contributes to their chief complaint: Patient runs 3 times per week, approximately 5km each time. Patient believes running contributes to their chief complaint.
- Mention any cessation of activity as a result of chief complaint, including when activity was stopped and why: Patient has reduced running frequency due to pain.
Footwear and orthotics:
- Current and most regularly worn shoes. List each mentioned with brand, model, materials of upper, fastening details and what activity they're used for: Patient wears Asics Gel-Kayano running shoes (mesh upper, lace-up fastening) for running and flat-soled trainers for everyday wear.
- Note any remarks made by practitioner regarding existing footwear including wear pattern, suitability for patient and activity, and condition of shoe: Practitioner noted that the running shoes are appropriate for the patient's foot type but are showing signs of wear.
- Note any current or previous use of orthotics and make specific reference to whether device was custom made, off-the-shelf, or a ready-made device that had been adjusted or somewhat customised by a professional. Mention age of device, whether device is currently worn and what activities or footwear it is used in and when: No current or previous use of orthotics.
Patient goals:
- What the patient hopes to achieve by seeking podiatric treatment: Patient hopes to reduce heel pain and return to running without pain.
ASSESSMENT OF CONDITION:
- List any areas of pain or tenderness on palpation and write as POP or TOP: TOP at the insertion of the plantar fascia on the calcaneus.
- Results of any assessments undertaken during today's consultation: Windlass test positive. Reduced ankle dorsiflexion.
- List any observations of anatomical or physical structures: Mild pronation noted.
Gait:
- Comment on any gait observations made by practitioner: Increased pronation during stance phase.
- Make reference to any pain or sensations experienced by patient during gait assessment: Patient reported pain at the heel during push-off.
TREATMENT OF CONDITION:
- List any treatment performed at today's consultation such as massage, dry needling, shockwave, strapping, padding, heel wedges or heel raises: Plantar fascia massage performed.
- List any instructions provided to the patient about removal of padding or strapping/taping: N/A
- List any advice given to patient such as rest, analgesia, footwear or activity modification, or other education: Advised to rest from running for one week. Advised to stretch plantar fascia and Achilles tendon daily. Advised to ice heel after activity. Advised to consider new running shoes.
- List any other podiatric care provided at today's consultation such as nail or skin care: N/A
- Make note of whether custom foot orthotics were recommended to treat chief complaint or not and whether they will be ordered now or considered at future consultations. List any specific prescription requirements for future orthotics such as padding, corrective measures, or practitioner and patient concerns around comfort or durability of new devices: Custom foot orthotics recommended. Prescription to include arch support and heel cup.
Prescribed exercises:
- List prescribed exercises, recommended reps, frequency, and goal reps, or any other specific instructions provided to patient: Plantar fascia stretch, 3 sets of 30 seconds, twice daily. Achilles tendon stretch, 3 sets of 30 seconds, twice daily.
- List any information provided about what the patient should feel during or after performing the exercises: Patient should feel a stretch in the arch and calf.
- Make note of whether the exercises are to be increased or changed in any way, and when this should occur: Exercises to be reviewed at next appointment.
PLAN:
- List when the patient is required to return for their next treatment: Return in 2 weeks.
- List any details of what issues need to be reviewed or addressed at their next consultation: Review pain levels, gait, and response to treatment.
- List any details that need to be communicated to or by the patient through email or WhatsApp after their appointment today: Patient to email a photo of their current running shoes.
(Use transcription to document and detail the following information.)
PRESENTING COMPLAINT:
[describe presenting complaint] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Chief complaint] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Mechanism of injury] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Date of onset or duration of injury] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Pain presentation, when pain occurs, type of pain, how long it lasts, specific movements that induce it, pain patterns recognised] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Aggravating factors such as type of activity, footwear, ground and floor surfaces, inclines or declines, specific foot or limb postures] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Alleviating factors such as rest, medications, change in footwear, modification of activity, professional treatment, at home treatment] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [List previously administered treatment for this specific condition, when it was undertaken, who administered it, and whether it had any effect on the condition] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
History of injury:
[Previous injuries acquired, same or different to current complaint, and when acquired] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Previous symptoms or pain in the feet or lower limbs] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Activity levels:
[List current sport, exercise, or activity undertaken. Include duration, frequency, intensity. Note whether patient believes this activity contributes to their chief complaint] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Mention any cessation of activity as a result of chief complaint, including when activity was stopped and why] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Footwear and orthotics:
[Current and most regularly worn shoes. List each mentioned with brand, model, materials of upper, fastening details and what activity they're used for] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Note any remarks made by practitioner regarding existing footwear including wear pattern, suitability for patient and activity, and condition of shoe] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Note any current or previous use of orthotics and make specific reference to whether device was custom made, off-the-shelf, or a ready-made device that had been adjusted or somewhat customised by a professional. Mention age of device, whether device is currently worn and what activities or footwear it is used in and when] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Patient goals:
[What the patient hopes to achieve by seeking podiatric treatment] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
ASSESSMENT OF CONDITION:
[List any areas of pain or tenderness on palpation and write as POP or TOP] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Results of any assessments undertaken during today's consultation] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[List any observations of anatomical or physical structures] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Gait:
[Comment on any gait observations made by practitioner] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Make reference to 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 any treatment 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.)
[Shockwave treatment should include pulses administered, intensity level, frequency level, size of head used, and what structure was treated] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Strapping should specify whether rigid sports tape or Rock Tape was used, which structures it was applied to, and any technique that was used such as low-Dye] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Dry needling should specify which structure was needled, how many needles were used, and whether any symptoms were experienced by the patient during administration] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Padding should specify the shape of the pad, whether felt padding was applied directly to the patient's foot or into the patient's footwear, and where it was placed] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[List any instructions provided to the 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 any 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 any 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.)
[Make note of whether custom foot orthotics were recommended to treat chief complaint or not and whether they will be ordered now or considered at future consultations. List any specific prescription requirements for future orthotics such as padding, corrective measures, or practitioner and patient concerns around comfort or durability of new devices] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Prescribed exercises:
[List prescribed exercises, recommended reps, frequency, and goal reps, or any other specific instructions provided to patient] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[List any information provided about what the patient should feel during or after performing the exercises] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Mention whether any specific equipment has been recommended or provided to help patient perform exercises] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Make note of whether the exercises are to be increased or changed in any way, and when this should occur] (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 any details of what issues need to be reviewed or addressed at their next consultation] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[List any details that need to be communicated to or by the patient through email or WhatsApp after their appointment today] (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.)
