Foot Pain Emergency Room Transcription Sample Report
CHIEF COMPLAINT: Right foot pain.
HISTORY OF PRESENT ILLNESS: The patient was running and playing football yesterday with some children and she felt an acute pain in her right heel. She states she has had this in the past. She was in the emergency room a couple of months back with similar symptoms. X-ray was done at that time and was read as negative for fracture. She has been better in the interim. However, she has not been completely asymptomatic. She states that she did not follow up with a primary care physician after being seen in the emergency room. She was given Percocet, which did provide temporary relief of symptoms; however, she never quite returned to normal afterwards. At this time, she has no numbness or tingling. She has no open areas, just the pain in the heel.
PAST MEDICAL HISTORY: Asthma. Bronchitis; she does take inhalers for this.
MEDICATIONS: Albuterol inhaler as needed.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: The patient does smoke about a pack of cigarettes a day. No alcohol or illicit drug use.
FAMILY HISTORY: Noncontributory.
REVIEW OF SYSTEMS: As mentioned, otherwise negative.
PHYSICAL EXAMINATION:
VITAL SIGNS: Blood pressure 104/68, pulse 82, respirations 18, and temperature 98.8.
GENERAL: The patient is awake, alert, and oriented, in no acute distress.
CHEST: Good breath sounds bilaterally with no wheezes, rales or rhonchi.
HEART: Regular rate and rhythm with no murmurs, rubs or gallops.
ABDOMEN: Soft, nontender, and nondistended. Good bowel sounds with no organomegaly.
MUSCULOSKELETAL: She has tenderness to palpation on the plantar surface of her right heel. She has full range of motion in her ankle. She has full range of motion in all of her toes. She has no appreciable numbness in the lower extremity. She has brisk cap refill. Peripheral pulses are intact. There is no evidence of bruising or swelling, no open areas, no lacerations.
EMERGENCY DEPARTMENT COURSE: This patient was seen for evaluation of her right foot pain. This seems to be a chronic and acute-on-chronic problem. She was seen here recently and had x-rays done. They are now available to view at this time. We did review the film. She does seem to have a large calcaneal spur, which is likely causing some degree of a plantar fasciitis. She has not taken anything for this at home. While she was here, we did arrange for podiatric followup. She is agreeable to this. She was given some exercises to do at home to flex the plantar surface of her foot. She was given Naprosyn to take for the pain.
DISCHARGE DIAGNOSES:
1. Foot pain.
2. Calcaneal spur.
PLAN:
1. The patient should follow up with podiatry as directed.
2. Naprosyn.
3. Stretching exercises.
DISPOSITION: The patient was discharged to home in stable condition.
