DATE OF SERVICE: MM/DD/YYYY
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old female who presents to the clinic today status post right heel pain for approximately three weeks. The patient did see her primary care provider, who ordered naproxen that the patient has been taking with positive relief and referred her to foot and ankle.
The patient has changed her footwear recently after she saw her primary care provider. She has not been icing. She has not gone to physical therapy. She has not done any stretching exercises. She states the pain is primarily worse at the end of her day. She denies fever, chills, calf pain, numbness or tingling.
PAST MEDICAL HISTORY: Hypertension, allergic rhinitis, GERD, osteopenia, and asthma.
PAST SURGICAL HISTORY: Stress incontinence and bladder reconstruction.
CURRENT MEDICATIONS: Advair, Boniva, calcium with vitamin D, enalapril, fish oil, Claritin, naproxen, vitamin D, and Zovirax.
MEDICATION ALLERGIES: Multiple, listed in chart.
SOCIAL HISTORY: The patient is divorced. She smoked socially in college but has had no smoking since that period of time. She has social alcohol intake. No illicit drug use.
FAMILY HISTORY: Noncontributory.
REVIEW OF SYSTEMS: All others negative.
PHYSICAL EXAMINATION:
GENERAL: Alert and oriented female sitting on the exam table, in no apparent distress.
SKIN: Warm, dry, and intact.
NEUROVASCULAR: +2 pedal pulses, brisk capillary refill. Sensation is intact throughout to light touch. No edema. Calf is supple and nontender proximally and distally.
MUSCULOSKELETAL: Dorsiflexion to neutral. Plantar flexion to 35 degrees. Strong inversion, eversion. Positive EHL, FHL, gastroc, tibialis anterior. Strength is 5/5. Mild tenderness to palpation over the plantar fascia insertion. No tenderness to palpation over the ATFL, CFL, deltoid, post-tib tendon, peroneals, Achilles tendon or plantar fascia insertion. Strength is 5/5. Nonantalgic gait with ambulation in a regular shoe.
DIAGNOSTIC DATA: Three views of her right foot were reviewed today that were obtained by her primary care provider that showed no acute fracture. There is a small Haglund’s bump present.
DIAGNOSIS: Status post right plantar fasciitis and gastroc contracture.
PLAN: We stated to the patient that at this point in time we would like to treat her for plantar fasciitis. We have given her a prescription for physical therapy. We have given her a night splint as well as home stretching exercises. We would like her to ice the plantar aspect of her foot 20 minutes 3 times daily and continue to ambulate in her new supportive sneakers. The patient verbalized understanding of this plan and is agreeable.
We would like to see her back in 6 weeks’ time, at which point in time if she is having no improvement, we would offer her a corticosteroid injection to the plantar aspect of her foot. The patient had the opportunity to ask questions, that were answered to her satisfaction. She is agreeable with this plan.
