-1. Blank-

January 1, 2050
Joe Sample

S: subjective

O: objective

- - Vitals
  - General
  - Lower Extremity Exam
  - Radiographs & Labs

A: assessment

- - Diagnosis

P: plan

- - Educate patient
  - Medication
  - New exams (lab or x-ray)
  - Return to clinic or discharge

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-2. How to Approach-

January 1, 2050
Joe Sample

S: subjective

NLDOCAT: Subjective findings
Nature – Do you have burning, tingling, shooting or numbness pain?
Location – Can you point with one finger where it hurts?
Duration – Months, weeks days?
Onset – Did this happen gradually or all at once?
Course – Getting better or worse? Radiating to other parts of the foot?
Aggravated – What makes it worse? Walking, certain shoes, resting?
Treatment – What have you tried to make it better?

Does he have any fevers, chills, nausea, or vomiting? Shortness of breath? Any trauma?

O: objective

VITALS:
Temperature – (36.5-37.6 C)
Heart Rate – (80-100 beats/min)
Respiratory Rate – (12-22 breaths/min)
Blood Pressure – (100-160 mmHg systolic)
Pulse Oximetry – (95-100 SpO2)
Pain Scale – (scale of 1-10)

GENERAL: awake, alert, oriented. Well groomed. Dressing intact.

LOWER EXTREMITY EXAM:

Neurologic (Neuro)
Light touch – 10g Semmes Weinstein Monofilament (5.07)
Vibratory – 128 Hz Tuning Fork
Sharp/dull – the blunt end and sharp end of a swab stick
Proprioception – move hallux up or down in space
Deep Reflexes – Achilles (L5-S2) and Patellar (L2-L4) with a reflex hammer
Superficial Reflexes – Babinski sign with a curved stroke of the reflex hammer

Vascular
Dorsalis Pedis (DP) and Posterior Tibialis (PT) pulses palpable
Mini-Doppler Ultrasound (Mono-, Bi-, Triphasic)
Capillary refill of the hallux (<3 seconds)
Digital hair presents (hair in toes = good blood flow)
Varicosities +/- presents
Edema (pitting edema vs non-) 1+ minima, 2+ moderate, 3+ severe
Skin temperature is cold/warm to the touch
Hot – inflammation or infection
Warm – normal healthy
Cold – poor blood flow

Muscular
Foot type – pes cavus, pes rectus, pes planus
Digital deformity – bunion, claw toe, hammer toe, mallet toe, hallux limitus
Joint ROM – Adequate ROM to MTPJ, STJ, and AJ without crepitus
Muscle Strength – 5/5 on all four quadrants
Equinus – Gastroc equinus, Gastroc-soleus equinus, Pseudoequinus
Gait analyses/ Biomechanics

Dermatologic (Derm)
Nails

Onychauxis – thickened, long nail
Onycholysis – separated nail
Onychocryptosis – ingrown nail
Onychogryphosis – ram’s horn nail
Onychomycosis – fungal nail

Skin

No hyperkeratotic lesions, verruca tissue, foreign body.
Mild edema, erythema but no open lesions, interdigit maceration
No varicosities, telangiectasis, pigmented lesion, venous stasis
Adequate fat padding to the plantar aspect of the foot

Ulcer – (length x with x depth) location? Granular or fibrotic base? roofing/undermining? tracking? tunneling? masserated or hypertrophic border? probes to a bone? Sangenous or serous drainage? Periwound erythema or edema? malodor present? Type: decubitus, ischemic, venous, neuropathic ulcer?

LABS: CBC, BMP, PT/INR, culture, gram stain

RADIOGRAPHS: Xray, CT scan, MRI, MRA

A: assessment

- - Think diagnosis or differential diagnosis
  - Think ICD 10 codes if comfortable

P: plan

- - Educate patient
  - Medication dispensed
  - New exams (labs or x-ray)
  - Pt. will return to the clinic in _ weeks

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-3. Example-

January 1, 2050
Joe Sample

A 65-year-old Male Diabetic type 2 (DMII) presents to podiatry clinic for (nature) throbbing pain (7/10) on the bottom of his (location) LEFT foot. He points at his big toe that is red, this started about (duration) 3 days ago, (onset) overnight all at once, (course) getting worse. He states that it is very (aggravated) sensitive even when putting on shoes or walking. He has (treatment) tried Tylenol, triple antibiotics cream, and soaking it but not helping. He denies any FCNV or SOB. Denies any recent trauma. States he was watching a football game eating wings, and drinking beer the night of the event.

- Vitals
  - Temperature – (36.6 C)
  - Heart Rate – (89 beats/min)
  - Respiratory Rate – (19 breaths/min)
  - Blood Pressure – (129/81 mmHg )
  - Pulse Oximetry – (93 SpO2)
  - Pain Scale – (7/10)
- General
  - Patient presents alert, awake, oriented. Well – groomed. Presents wearing flip-flops and a cane.
- Lower Extremity Exam
  - Neuro – Epicritic sensation intact, no LOPS with 5.07 SWMF
  - Vasc – DP/PT palpable pulses, Cap refill <4 sec, digital hair present, local edema +1 on Left 1st MTPJ. No cyanosis.
  - Musc – Pes planus, 5/5 on all 4 quadrants, no digital deformities
  - Derm – Thick yellow, discolored, dystrophic, elongated nails x10.
    - Local edema, and erythema to Left 1st MTPJ.
    - No hyperkeratotic lesions, verruca tissue, foreign body.
    - Mild edema, erythema but no open lesions, interdigit maceration
    - No varicosities, telangiectasis, pigmented lesion, venous stasis
    - Adequate fat padding to the plantar aspect of the foot
- Radiographs & Labs
  - LEFT foot AP and Lateral shows 1st MTPJ punch out lesion with an overhanging edge (Martel’s sign), and cloudy radiolucency in 1st MTPJ space. My impression is acute gouty arthritis of LEFT 1st MTPJ.

- - Diagnosis: A 65-year-old Male DMII with Left 1st MTPJ acute gout – stable.
  - ICD 10: (optional)
    - Left foot pain
    - DM II
    - Gouty arthritis
    - onychomycosis

- Educate patient on a proper healthy food diet, avoid high cholesterol and fatty foods. Educate on reoccurrence of gouty attacks if continued diet. Educate patient on proper diabetic paliative care; will send with diabetic foot care flyer and order new diabetic shoes/socks.
- Medication: Rx Colchicine 1.2 mg PO at first sign of a flare, then 0.6 mg 1 hr later
- Exams: Evaluated x-ray radiographs of Left foot AP, and Lateral view in clinic
- Dispenced: Fitted for Diabetic shoegear with wide toe box. Dispenced diabetic white socks.
- Sharp debridement of nails x10, without incidence.
- Return to clinic in 3 weeks or sooner if problems arise.