Patient: John Doe
Account No: 123456
Date: 1 November 2024
Chief Complaint:
This 45-year-old male presents today stating that he feels a sharp object in his right foot. The condition has been present for two weeks. Patient recalls stepping on a piece of glass while walking barefoot in his garden. Patient relates experiencing pain, tenderness, and redness in the affected area. At home, patient attempted to soak the foot and remove the glass but was unsuccessful.
Allergies:
None
Medications:
Ibuprofen 200 mg, twice daily
Past Medical History:
Hypertension
Past Surgical History:
Appendectomy in 2010
Family History:
Father has a history of diabetes
Social History:
Non-smoker, occasional alcohol use
Immunizations:
Up to date
Review of Systems:
- Constitutional: No fever, fatigue, or weight changes
- Cardiovascular: No chest pain or palpitations
- Endocrine: No thyroid issues
- ENMT: No sore throat or nasal congestion
- Eyes: No vision changes
- Gastrointestinal: No nausea or vomiting
- Genitourinary: No urinary symptoms
- Immunologic: No known immunologic issues
- Integumentary: Redness and tenderness in the right foot
- Lymphatic: No lymphadenopathy
- Musculoskeletal: Pain in the right foot
- Neurological: No headaches or dizziness
- Psychiatric: No anxiety or depression
- Respiratory: No cough or shortness of breath
Physical Exam:
Vitals: Blood pressure 130/85 mmHg, Heart rate 78 bpm, Temperature 36.8°C
Constitutional:
Patient is a pleasant, well-groomed male, in mild distress due to foot pain. Oriented to person, place, and time. Mood and affect appear appropriate.
Cardiovascular:
Skin temperature is warm in both feet.
Dorsalis pedis pulses are 2+ left and 2+ right.
Posterior tibial pulses are 2+ left and 2+ right.
Capillary fill time is less than 2 seconds left and right.
No edema noted.
No varicosities observed.
Skin:
Skin color is noted to be normal.
Skin texture is noted to be normal.
Examination of the right foot reveals erythema and the presence of a dark object under the skin. The area shows no signs of infection or purulent drainage.
Neurological:
Vibratory sensation is intact in both feet.
Sharp-dull sensation is intact in both feet.
Light touch sensation is intact in both feet.
Deep tendon reflexes are present.
Coordination is normal.
Musculoskeletal:
Muscle strength of extremities is normal.
Manual muscle testing is 5 out of 5 for all groups.
Impression:
Foreign body in the right foot, likely glass shard.
Plan:
- Prescribed antibiotics to prevent infection.
- Advised warm soaks and elevation of the foot.
- Scheduled for removal of the foreign body in the clinic.
- Follow-up in one week to assess healing.
X-rays were taken and reviewed, confirming the presence of a foreign body.
I&D procedure scheduled for foreign body removal.
