First Consult Bunion

CONSULTATION NOTE: PATIENT NAME: Mr. John Smith AGE: 55 years MAIN COMPLAINT: The patient presents with a painful bunion on his left foot. The pain is located at the base of the big toe and is exacerbated by walking and wearing shoes. He reports that the pain has been gradually worsening over the past year. HISTORY OF MAIN COMPLAINT: The patient first noticed a small bump on the inside of his left foot approximately one year ago. Over time, the bump has increased in size, and the pain has become more frequent and intense. He denies any specific injury or trauma to the foot. The pain is typically worse at the end of the day and after prolonged standing or walking. He has tried over-the-counter pain relievers, which provide minimal relief. TREATMENT TO DATE: The patient has tried over-the-counter pain relievers, including ibuprofen and paracetamol, with limited success. He has also tried wearing wider shoes, which has provided some temporary relief. INVESTIGATIONS TO DATE: X-rays: X-rays of the left foot were taken at an outside facility six months ago, showing a prominent bunion deformity. ACTIVITY LEVEL: Occupation: Accountant Sports: Occasional walking Hobbies: Gardening EXPECTATIONS: 1. Relief from pain. 2. Improved ability to walk comfortably. 3. Correction of the bunion deformity. PAST MEDICAL HISTORY: The patient has a history of hypertension, well-controlled with medication. He denies any other significant medical conditions. Smoker: No DVT risk factors or history: No PAST SURGICAL HISTORY: The patient had an appendectomy at age 10. CURRENT MEDICATION: Lisinopril 10mg daily for hypertension. ALLERGIES: No known drug allergies. CLINICAL EXAMINATION: Gait: Antalgic gait, favouring the left foot. Walking aid: None BMI: 28 Ht: 1.78 m. Wt: 89 kg. INSPECTION: There is a prominent bunion deformity on the left foot with medial deviation of the first metatarsal and lateral deviation of the great toe. There is also associated erythema and swelling over the bunion. PALPATION: Tenderness: Tenderness to palpation over the medial eminence of the first metatarsal head. Masses: No palpable masses other than the bunion itself. Crepitus: No crepitus appreciated. Temperature: No increased temperature. Pulses: Dorsalis pedis and posterior tibial pulses are palpable and strong. Neurological: Intact sensation and motor function in the foot and ankle. RANGE OF MOTION: Reduced range of motion at the first metatarsophalangeal joint due to pain and deformity. Dorsiflexion is limited to 10 degrees, and plantarflexion is limited to 20 degrees. STRESS TESTS: First ray instability: No instability appreciated. Bunion deformity reducible: The bunion deformity is partially reducible with manual manipulation. Push up test: Negative. JOINT ABOVE AND BELOW: The ankle and knee joints are stable and have a full range of motion. RADIOLOGICAL INVESTIGATIONS: X-ray: Date: 1 November 2024. X-rays confirm the presence of a bunion deformity with an increased intermetatarsal angle and hallux valgus angle. X-ray metrics: IMA: Left 15°, right 2° HVA: Left 40°, right 5° DMAA: Left 10°, right 2° Interphalangeus angle: Left 5°, right 2° MRI: Date: Not performed. Ultrasound: Date: Not performed. CT Scan: Date: Not performed. LABORATORY INVESTIGATIONS: Not performed. ASSESSMENT: Left foot bunion deformity (hallux valgus) with associated pain and functional limitations. PLAN: 1. Discuss conservative management options, including shoe modifications, padding, and orthotics. 2. Consider referral to a podiatrist for custom orthotics. 3. Discuss surgical options, including bunionectomy, if conservative measures fail. 4. Schedule a follow-up appointment in 6 weeks to reassess the patient's condition and response to treatment. 5. Provide patient education on bunion care and management. 6. Prescribe pain medication as needed. 7. Order X-rays of the left foot for pre-operative planning if surgery is considered.