Podiatry Template - Dr. B

History of present illness

[Document in detail the patient's history of present illness, including the nature, location, duration, onset, and any past treatments related to the current complaint. Write this in a narrative format] For example- The patient presents with a painful corn on the right fifth toe. He has had persistent pain for over 3 months. Past treatments have included, shaving the corn, using salicylic acid corn remover pads and wider shoes.

Social history

[Document the patient's social history, including details about work, exercise habits, smoking status, and drug use. Only include information as discussed in the encounter transcript]

Family history

[Include any relevant family medical history that may contribute to the patient's condition.]

Surgical history

[List any past surgical procedures that are relevant to the patient's current podiatric condition or chief complaint]

Vascular exam

[Document findings from the vascular examination, including any abnormalities or significant observations. If no relevant findings, state "No significant findings"] Dorsalis pedis and posterior tibial pulses are palpable at 2/4 bilaterally. Capillary fill time to the hallux unstressed is less than or equal to 3 seconds.

Pedal neurological exam

[Record the results of the pedal neurological examination, noting any deficits or abnormalities. If no relevant findings, state "No significant findings"] Pedal neurological evaluation shows protective sensation to the distal and proximal target areas as tested with a 10 gram monofilament. Vibratory , light touch and proprioception are also with in normal limits. Muscle strength testing to all four quadrants is with in normal limits.

Ortho/Biomechanical exam

[Provide details of the orthopedic or biomechanical examination, including any relevant findings. If no relevant findings, state "No significant findings"] Standard base of gait shows a decreased longitudinal medial arch height with the relaxed calcaneal stance position slightly everted to the ground surface. Subtlar joint range of motion shows 2/3 inversion and 1/3 eversion bilaterally. Ankle joint dorsiflexion shows approximately 10 degrees of dorsiflexion with the knee extended bilaterally. Gait analysis shows pronation in the mid stance phase of gait bilaterally.

Dermatological exam

[Describe the findings from the dermatological examination, including any skin-related observations. If no relevant findings, state "No significant findings"]

Impression

[Provide a numbered list of diagnostic impressions, including ICD9 diagnostic codes for each identified condition.] For example - 1. [Diagnosis 1] [ICD 9] 2. [Diagnosis 2] [ICD 9]

Treatment plan

[Outline the treatment plan as a numbered list including any medications, therapies, or follow-up recommendations. **Include a note at the end of the plan that says the encounter was recorded using AI with the patient's consent and the note was carefully reviewed before submission to the medical chart. Make this note bold and underlined.**] For example - P: 1. Initiate topical efinaconazole (Penlac) for affected nail(s), to be applied nightly for an eleven-month course. 2. Provide four refills of topical medication; advise to obtain from lowest-cost pharmacy. 3. Instruct on calf muscle stretching exercises twice daily for Achilles tendon tenderness. 4. Monitor response to topical therapy; consider oral antifungal therapy and liver function testing if topical treatment fails or if patient elects oral therapy in the future. **__This encounter was recorded using AI with the patient's consent and the note was carefully reviewed before submission to the medical chart.__**