podiatric practice templates full_final edit

PODIATRIC

PRACTICE

TEMPLATES

Brooks Foot & Ankle

Associates

Medicine and Surgery of the

Foot and Ankle

BRADIE BRITT

JESSICA VERVOORT KENNETH OMS

SUZANNE JEAN-BAPTISTE

2201 E Nine Mile Rd Pensacola, FL 32514 Telephone : 850-479-6250 Fax : 850-479-6247

Email : [email protected]

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Contents List of Figures .....................................................................................................................................6

Introduction .......................................................................................................................................8

Dermatology ......................................................................................................................................8

Benign Neoplasm/Lesion of uncertain behavior ................................................................................8

Dermatitis - Established Patient - Biopsy - AFC ................................................................................ 10

Dermatological Exam Normal ........................................................................................................ 12

Foreign Body Health & Physical...................................................................................................... 12

Hyperkeratosis- Initial ................................................................................................................... 15

Hyperkeratosis - Follow-up ............................................................................................................ 18

Hyperkeratosis Debridement ......................................................................................................... 19

Incision & Drainage – Established Patient ....................................................................................... 19

Incision & Drainage –New Patient .................................................................................................. 20

Ingrown Nail – Follow-up............................................................................................................... 22

Kissing corn .................................................................................................................................. 23

Lesion Description ........................................................................................................................ 25

Nail Avulsion - Initial ..................................................................................................................... 25

Nail Avulsion - Follow-up ............................................................................................................... 27

Onychomycosis - Established Patient ............................................................................................. 27

Onychomycosis - New Patient........................................................................................................ 29

Phenol and Alcohol Matrixectomy ................................................................................................. 31

Phenol and Alcohol Matrixectomy – Established Patient ................................................................. 32

Phenol and Alcohol Matrixectomy – New Patient ........................................................................... 33

Partial Nail Avulsion – New Patient ................................................................................................ 35

Partially Avulsed Nail..................................................................................................................... 37

Pigmented Lesion ......................................................................................................................... 39

PinPointe - Initial .......................................................................................................................... 41

PinPointe - Follow-up .................................................................................................................... 44

Ulceration - Initial Visit .................................................................................................................. 45

Ulceration - Follow-up................................................................................................................... 47

Ulceration of Toe - Initial ............................................................................................................... 48

Verruca - Initial ............................................................................................................................. 51

Verruca - Follow-up....................................................................................................................... 53

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Musculoskeletal ............................................................................................................................... 53

Achilles Tendonitis - Initial ............................................................................................................. 53

Achilles Tendonitis - Follow-up ...................................................................................................... 57

Achilles Wrap ............................................................................................................................... 58

Ankle Exam................................................................................................................................... 58

Ankle instability/Sprain - Initial ...................................................................................................... 59

Ankle Sprain ................................................................................................................................. 62

Aspiration..................................................................................................................................... 63

Bunion Exam ................................................................................................................................ 63

Bunion - Initial .............................................................................................................................. 64

Bunion - Follow-up........................................................................................................................ 65

Calcaneal Apophysitis - Initial ........................................................................................................ 66

Capsulitis - Initial........................................................................................................................... 69

Capsulitis - Follow-up .................................................................................................................... 72

Charcot - AFO ............................................................................................................................... 72

Contusion Foot/Toe - Initial Visit .................................................................................................... 76

EPAT ............................................................................................................................................ 78

ETOH Injection.............................................................................................................................. 79

ETOH Injection.............................................................................................................................. 80

Excision Foreign Body.................................................................................................................... 80

Fracture - Initial Visit ..................................................................................................................... 82

Fracture - Follow-up Visit .............................................................................................................. 85

Gait Analysis ................................................................................................................................. 85

Gout - Initial Visit .......................................................................................................................... 86

Gout - Follow-Up Visit ................................................................................................................... 88

Hallux Rigidus - Initial Visit............................................................................................................. 89

Hallux Rigidus – Follow-up - Steroid Injection ................................................................................. 92

Joint Injection ............................................................................................................................... 93

Hallux Valgus ................................................................................................................................ 93

Hammertoe - Initial Visit ............................................................................................................... 94

Hammertoe - Initial Visit - Arthroplasty .......................................................................................... 97

Hammertoe – Follow-up.............................................................................................................. 100

Heel Exam - Ortho Exam.............................................................................................................. 101

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Joint Injection ............................................................................................................................. 101

Osteoarthritis - Initial Visit ........................................................................................................... 102

Osteoarthritis Follow-up.............................................................................................................. 104

Peroneal Tendonitis .................................................................................................................... 105

Pes Planus .................................................................................................................................. 107

Plantar Fasciitis - Initial Visit ........................................................................................................ 111

Plantar Fasciitis - D/C .................................................................................................................. 114

Plantar Fasciitis - Follow-up - Steroid Injections ............................................................................ 115

Plantar Fasciitis - Follow-up - Surgery Recommended.................................................................... 117

Plantar Fibroma .......................................................................................................................... 118

Posterior Tibial Tendonitis - Initial Visit ........................................................................................ 122

Posterior Tibial Tendonitis - Follow-up ......................................................................................... 124

Sesamoiditis – Initial Visit ............................................................................................................ 126

Sinus Tarsitis – New Patient ......................................................................................................... 129

Tailor's Bunionette Deformity ...................................................................................................... 132

Tarsal Tunnel Syndrome - Initial Visit............................................................................................ 134

Tarsal Tunnel Syndrome – Established Patient .............................................................................. 137

Tinea Pedis - Initial Visit............................................................................................................... 138

Tinea Pedis - Follow-up ............................................................................................................... 140

Neurology ...................................................................................................................................... 141

Neuroma - Initial Visit ................................................................................................................. 141

Neuroma - Follow-up - Steroid injection ....................................................................................... 143

Neuroma - Follow-up - Surgery Recommended............................................................................. 144

Neuroma Discharge .................................................................................................................... 146

Neuropathy ................................................................................................................................ 146

Surgery .......................................................................................................................................... 148

Amputation at the MPJ ............................................................................................................... 148

Apligraft Op report...................................................................................................................... 149

Arthroplasty Digit........................................................................................................................ 150

Biopsy epidermal Nerve density................................................................................................... 151

Biopsy Lesion.............................................................................................................................. 153

Chilectomy ................................................................................................................................. 154

Informed Consent – Achilles Tendon Repair ................................................................................. 157

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CRYOSURGERY - Neuroma ........................................................................................................... 159

ENFD post op 1 ........................................................................................................................... 162

ENFD post op 2 ........................................................................................................................... 163

Exostectomy ............................................................................................................................... 164

Exostectomy/Condylectomy of Toe op-report .............................................................................. 166

Exostosis Distal toe ..................................................................................................................... 167

Flexor Tenotomy......................................................................................................................... 168

Metatarsal Ostectomy................................................................................................................. 169

Post-op Arhtrodesis .................................................................................................................... 171

Post-op Bunionectomy ................................................................................................................ 172

Post-op Visit 3 ............................................................................................................................ 173

Post-op Visit 4 ............................................................................................................................ 173

Post-op Visit Follow-up ............................................................................................................... 174

Post-op Visit Initial ...................................................................................................................... 175

Pre-op Consent ........................................................................................................................... 176

Pre-op Consent ........................................................................................................................... 176

Removal of Painful Internal Fixation............................................................................................. 179

Silver Bunionectomy ................................................................................................................... 182

Correspondence ............................................................................................................................. 183

EPAT Customer Satisfaction Survey .............................................................................................. 183

Letter of Medical Necessity ......................................................................................................... 184

Letter of Medical Necessity - 64455 ............................................................................................. 185

Letter of Medical Necessity - Orthotics or Diabetic Insoles/Shoes .................................................. 185

Post-op Instructions .................................................................................................................... 186

Post-op Instructions - Matrixectomy ............................................................................................ 189

Post-op Instructions - Verruca ..................................................................................................... 191

Durable Medical Equipment ............................................................................................................ 192

AFO Prescription - Casting ........................................................................................................... 192

AFO Prescription - Mini-templates ............................................................................................... 192

AFO Dispensing........................................................................................................................... 192

AFO – Follow-up ......................................................................................................................... 193

Aircast Ankle Brace ..................................................................................................................... 194

Ankle Brace ................................................................................................................................ 195

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Dispensing Orthotics ................................................................................................................... 196

Durable Medical Equipment Prescription ..................................................................................... 196

Leg Cast...................................................................................................................................... 197

Night Splint ................................................................................................................................ 198

Non-pneumatic Walker ............................................................................................................... 199

Non-pneumatic Walker for Bunion............................................................................................... 200

Orthotic Casting .......................................................................................................................... 200

Orthotic Follow-up ...................................................................................................................... 202

Diabetic ......................................................................................................................................... 204

Diabetic Neurological and Vascular Exam ..................................................................................... 204

Diabetic Shoe Dispensal .............................................................................................................. 207

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List of Figures Figure 1 - Benign Neoplasm on Left.................................................................................................... 10

Figure 2 – Dermatitis......................................................................................................................... 12

Figure 3 - Screw Foot and Flip-Flop Sandal ......................................................................................... 15

Figure 4 - Healing Progression of Postoperative Ingrown Toenail ......................................................... 23

Figure 5 - Soft Kissing Corn ................................................................................................................ 24

Figure 6 - Proximal subungual onychomycosis (arrow) ........................................................................ 29

Figure 7 – Phenol portion of Matrixectomy ........................................................................................ 35

Figure 8 - Lesion noted by patient after a training run while wearing joggers ....................................... 41

Figure 9 – Pinpoint laser producer ..................................................................................................... 43

Figure 10 – After application of Pinpoint ............................................................................................ 44

Figure 11 - PinPointe Laser machine .................................................................................................. 44

Figure 12 – Illustration of Ulcerated Foot ........................................................................................... 50

Figure 13 – Verruca Plantar Wart....................................................................................................... 52

Figure 14 – Illustration of Achilles Tendonitis...................................................................................... 55

Figure 15 - AirHeel™ ......................................................................................................................... 56

Figure 16 - Aircast® ........................................................................................................................... 56

Figure 17 – Achilles Wrap .................................................................................................................. 58

Figure 18 – Bunion ............................................................................................................................ 63

Figure 19 – Illustration describing Calcaneal Apophysitis ..................................................................... 69

Figure 20 – Capsulitis ........................................................................................................................ 71

Figure 21 – Illustration of Normal Foot............................................................................................... 75

Figure 22 - Illustration of Charcot Foot ............................................................................................... 76

Figure 23 - Patient presenting with Charcot Foot ................................................................................ 76

Figure 24 - Contusion on Left Ankle ................................................................................................... 78

Figure 25 – X-ray Examples of Foreign Body ....................................................................................... 81

Figure 26 – Antenor/Posterior View of Fibula Fracture........................................................................ 84

Figure 27 – Lateral and Antenor/Posterior View of Fibula Fracture ...................................................... 84

Figure 28 – Illustration of Gait Analysis .............................................................................................. 86

Figure 29 - Gout in Left Foot .............................................................................................................. 89

Figure 30 –Photograph and X-ray of Hallux Rigidus deformity.............................................................. 92

Figure 31 - Illustration of Joint Injection ............................................................................................. 93

Figure 32 – Hallux Valgus of the Left Foot........................................................................................... 94

Figure 33 – Before and After Demonstration of Hammertoe Surgery ................................................... 97

Figure 34 – X-Ray of Before and After Hammertoe Surgery ................................................................. 99

Figure 35 – Demonstration of a Joint Injection.................................................................................. 101

Figure 36 – Illustration of Osteoarthritis ........................................................................................... 104

Figure 37 – Illustration of Peroneal Tendonitis.................................................................................. 107

Figure 38 – Illustration of Pes Planus................................................................................................ 110

Figure 39 – Patient with Pes Planus.................................................................................................. 110

Figure 40 – Illustration Plantar Fasciitis ............................................................................................ 113

Figure 41 – Example of Insert .......................................................................................................... 115

Figure 42 – Patient Receiving Plantar Fascia Injection ....................................................................... 116

Figure 43 – Plantar Fasciitis Surgery ................................................................................................. 118

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Figure 44 – Patient Presenting with Plantar Fibroma......................................................................... 121

Figure 45 – Illustration about Plantar Fibroma .................................................................................. 121

Figure 46 – Illustration of Posterior Tibial Tendonitis ........................................................................ 124

Figure 47 – MRI of Sesamoiditis ....................................................................................................... 129

Figure 48 – X-Ray of Sinus Tarsitis .................................................................................................... 131

Figure 49 – Patient with Bunion and Tailor’s Bunion ......................................................................... 134

Figure 50 – Illustration of Tarsal Tunnel Syndrome............................................................................ 136

Figure 51 – Patient with Tinea Pedis ................................................................................................ 140

Figure 52 – Surgery of Neuroma ...................................................................................................... 145

Figure 53 - X-ray of Internal Fixation ................................................................................................ 181

Figure 54 - Example of Interval Fixation in place ............................................................................... 181

Figure 55 - Example of Silver Bunionectomy ..................................................................................... 183

Figure 56 - Aircast® Airsport™ Ankle Brace ....................................................................................... 194

Figure 57 - DonJoy® RocketSoc™ Ankle Support Brace ...................................................................... 195

Figure 58 - Examples of Durable Medical Equipment......................................................................... 197

Figure 59 - Leg Cast on Left Foot ...................................................................................................... 198

Figure 60 - DeRoyal® Night Splint..................................................................................................... 199

Figure 61 - Aircast® Walking Boot .................................................................................................... 200

Figure 62 - Example of Clay Casting.................................................................................................. 201

Figure 63 - Example of plaster casting .............................................................................................. 201

Figure 64 - Examples of Orthotics .................................................................................................... 203

Figure 65 - Before and After of Orthotics.......................................................................................... 203

Figure 66 - Display of Diabetic Shoes................................................................................................ 208

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Introduction Group 2 is editing a document for a podiatry group in Pensacola Florida. This document will be used by

the podiatric practice to expedite their patient record keeping process. Brooks Foot & Ankle Associates

provided us with the templates they use to record patient notes. I visited the practice and copied 180

pages of templates out of their patient record keeping software, TrakNet. With the help of Joshua Britt,

DPM, an associate of the practice, we were able to remove templates which did not need editing.

The brackets that are used throughout the document are needed so that TrakNet can create quick fill options within the program.

Dermatology

Benign Neoplasm/Lesion of uncertain behavior Patient: [Patient. Name] Account No: [Patient. AcctNo] Date: [Date]

Subjective: Patient presents today c/o a [painful, non-painful] [lesion, growth, mole, wart, dark spot,

hard area, bleeding lesion] on the [right, left] [foot, ankle, leg]. The area of concern is located [on,

between, on the bottom of, beneath, on top of, on the right side of, on the left side of, on back of, on

front of] the [the sulcus region, the heel, the arch, the 1st MTPJ, the 2nd MTPJ, the 3rd MTPJ, the 4th

MTPJ, the 5th MTPJ, the big toe, the 2nd toe, the 3rd toe, the 4th toe, the 5th toe] [the foot, the ankle,

the heel, the leg]. She [has, has not] noticed recent changes in the area. She [has, does not have] a

personal history of skin cancer. She [has, has not] been previously diagnosed with and treated for other forms of cancer. There [is a, is no] known family history of skin cancer.

Objective: PMH, PSH, Medications: Unchanged since last visit. The patient's neurovascular status of

bilateral lower extremity is unchanged since last visit.

Dermatological: The lesion is located on the [plantar, dorsal, medial, lateral, anterior, posterior] surface

of the [right, left] [foot, ankle, leg]. The lesion is [hyperkeratotic, hyperpigmented, hypopigmented,

raised, flat, red, blue, black, white, dark, papular, macular, isolated, singular, multilobulated, soft, firm,

freely movable, fixed, intraepidermal, dermal, subcutaneous, deep fascial, osseous, chalky, blanchable,

non-blanchable, irregular borders, round, triangular, square, stellate, translucent, smooth, course, with

interrupted skin lines, well circumscribed, bleeding, crusted, escharotic, nucleated, ulcerated]. After

inspection/debridement the lesion does not reveal any verruca-type tissue, retained foreign bodies, or

cardinal signs of infection. Otherwise, there is no evidence of edema, erythema, ecchymosis, open

lesions, interdigital maceration or signs of bacterial or fungal infection of bilateral lower extremities. No

varicosities, telangectasias, pigmented lesions or signs of venous stasis changes bilateral lower extremities. [Inadequate, Adequate] fat padding to the inferior aspect of each foot appreciated.

Musculoskeletal: [Pain, No pain] is noted to palpation of the lesion. It [does, does not] appear to be

intimately associated with a bony prominence or foot deformity. [Bunion, Hammertoe, Tailor's bunion,

Metatarsal, Tarsal, Rearfoot] deformity [is, is not] noted.

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Assessment: [Benign neoplasm, Deformed metatarsal, Porokeratoma discrita, Neoplasm of uncertain

behavior, Fibroma, Inclusion cyst, Foreign body granuloma, pyogenic granuloma, verruca, IPK, Blue

nevus, Junctional nevus, Basal cell carcinoma, squamous cell carcinoma, possible melanoma]

Plan:

1) I have discussed the treatment options with the patient in detail, including non-surgical vs. surgical care. Based on my findings I recommended

[Non-surgical care, surgical management] of the condition. I recommended [excision of the entire lesion,

punch biopsy, shave biopsy, excisional biopsy, with histopathologic identification.][Destruction of the

lesion with][Serial debridement and application of Canthecur, liquid nitrogen, off-loading, periodic paring of the lesion, modifications of shoe inserts, daily application of aperture pads].

2) The patient desires [non-surgical care, surgical management] for the condition. Treatment today

consisted of [paring of the lesion followed by the application of Canthecur, destruction of lesion with

liquid nitrogen, palliative off-loading, biopsy, surgical planning, counseling and a comprehensive

informed consent session during which the patient was afforded the opportunity to ask any questions

and all questions were answered to the best of my ability]. [The patient was advised of the potential

risks and complications associated with excision of the lesion. She was advised that an infection may

occur, the lesion may recur, a painful scar might develop, numbness and swelling may occur and persist,

that if the lesion is found to be malignant a referral to an oncologist and/or other specialists may be

needed, that additional surgical and non-surgical treatments may be required, an no guarantees were

given as to outcome.]

3) Comprehensive oral and written instructions were provided to the patient for aftercare. She was

instructed to remain [non-weightbearing, partial weightbearing, fully weightbearing] on the affected

limb. She was also advised to [keep the area dry, keep the foot elevated, to take a few days off work, to

use OTC Tylenol, Ibuprofen, or Aleve for pain control]. Patient was reappointed for [5 days, 1 week, 2

weeks, 3 weeks, 1 month, PRN] for follow-up. The patient was advised to contact the office immediately if problems arise.

_____________________________

Dr. [User. Name]

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Figure 1 - Benign Neoplasm on Left

Dermatitis - Established Patient - Biopsy - AFC

Patient: [Patient.Name] Account No: [Patient.AcctNo] Date: [Date]

Subjective: This is a [Patient.Age] year-old patient where [Patient.heshe] presents today to the office

with a [new, existing, flare up, reoccurring, post op complication] skin complaint of [hives, pimples,

itchiness, inflammation, irritation] on their [left, right, bilateral] lower extremity. It has not responded to

[topical OTC anti-fungals, drying agents, foot soaks, and other conservative treatment options]. Patient

[has, has not] had a similar condition previously and denies any recent trauma or inciting

events. Patient [denies, relates] a family history of this condition.

Allergies: [Allergies]

Medications: [Meds]

Past Medical History: [PMH]

Past Surgical History: [PSH]

Past Family and Social History: [PFSH]

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Review of Systems:

GI: [GI]

Musculoskeletal: [MSK]

Integumentary: [Integumentary]

Hematologic/Lymphatic: [Lymphatic]

Allergic/Immunologic: [Immunologic

Objective: The patient is appropriately dressed, articulate, awake, alert, and oriented x 3, appears

stated age and looks to be in [good*,poor] health.

Vascular: Dorsalis pedis pulses are [0,1,2*,3,4]/4 left, dorsalis pedis pulses are [0,1,2*,3,4]/4 right, and

posterior tibial pulses are [0,1,2*,3,4]/4 left, posterior tibial pulses are [0,1,2*,3,4]/4 right. Capillary

filling time with the leg elevated is [<5 right*, 5 right,>5 right, <5 left*, 5 left,>5 left] seconds at the level

of the digital tufts. There [is, are no] ischemic skin changes evident in [left, right, bilateral*] lower

extremities. There [is, is not*] [edema*, pitting edema +??, non-pitting edema +??] noted lower extremity [left, right, bilateral*]. Digital hair [present*, not present]

Neurological: Epicritic sensation including sharp-dull, light touch, proprioception, 2-point discrimination

(< 12 mm at level of hallux tuft), vibration (128 MHz tuning fork) and protective threshold (10.0 gram

monofilament) are [intact*, diminished] and [with, without*] focal motor or sensory deficit [left, right,

bilateral*] lower extremities. Normal muscle mass appreciated to both the lower extremity and foot

[left, right, bilateral*]. [Negative*, Positive] Mulder`s sign to the interspaces of both feet.

Dermatological: There is questionable skin abnormality noted on [plantar, dorsal, medial, lateral] [foot,

ankle]. There [is, is not] small vesicle formation throughout. Otherwise, there is no evidence of edema,

ecchymosis, or signs of bacterial infection of bilateral lower extremities. No varicosities, telangectasias,

pigmented lesions or signs of venous stasis changes to bilateral lower extremities. Adequate fat padding to the inferior aspect of each foot appreciated.

Musculoskeletal: One notes a [rectus*, planus, cavus] foot type with [mild, no] gastroc-soleus equinus

deformity. One notes [no*, mild] evidence of limb length discrepancy. Range of motion of the ankle,

subtalar and midtarsal joints [are, are not] painfree and within normal limits. There are [no*,

some] [flexible semi-rigid, rigid] digital contractures noted [1L, 1R, 2L, 2R, 3L, 3R, 4L, 4R, 5L, 5R]. Muscle strength is [1, 2, 3, 4, 5]/5 for all four lower extremity muscle groups.

Assessment: [692.9]

Plan: [99202] [11100]

All questions were answered in detail and they are to return to office in [one, two] weeks.

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Figure 2 – Dermatitis

Dermatological Exam Normal

Dermatological Exam: There is no evidence of edema, erythema, ecchymosis, open lesions, interdigital

maceration, or signs of bacterial or fungal infection bilateral lower extremities. No varicosities,

telangectasias, pigmented lesions or signs of venous stasis changes bilateral lower extremities.

Foreign Body Health & Physical

Chief Complaint: This [patient.Age] year old [patient.Gender] presents today stating that [patient.heshe]

thinks something is in [patient.hisher] [right, left] foot. Condition has been present for [1, 2, 3, 4, 5, 6, 7,

8, 9, a few, several] [day, days, week, weeks, month, months, year, years]. Patient [recalls stepping on

glass, thinks it’s a wood splinter, does not recall any trauma to the area or stepping on anything. Patient

relates [pain, tenderness, redness, drainage]. At home, patient [has been soaking area, did try to remove foreign body, has not performed any home care].


Meds: [Meds]

PMH: [PMH]

PSH: [PSH]

Family History: [Family History]

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Social History: [Social History]

Immunizations: [Immunizations]

Review of System:

Constitutional: [Constitutional]

CV: [CV]

Endocrine: [Endocrine]

ENMT: [ENMT]

Eyes: [Eyes]

GI: [GI]

GU: [GU]

Immunologic: [Immunologic]


Lymphatic: [Lymphatic]

MSK: [MSK]

Neurological: [Neurological]

Psychiatric: [Psychiatric]

Respiratory: [Respiratory]

Physical Exam:

[Vitals]

Constitutional exam: Patient is a pleasant, [patient.Age] year old [patient.Gender], [in no apparent

distress*, looks given age*, well developed*, good attention to hygiene*, alert, breathing comfortably,

cachectic, chronically ill, comfortable, cooperative, distressed, frail, in no apparent distress,

malnourished, moderately overweight, moderately uncomfortable, morbidly obese, non-toxic, oriented,

overweight, petite, pleasant, pregnant, sleepy, somewhat tired, thin, uncomfortable, undernourished, with a pleasant expression with anasarca].

Oriented to [person*, place*, time*, person but not place or time, place but not person or time, time but not person or place].

Mood and affect appear [normal and appropriate to situation*, agitated, angered, anxious, appropriate

for age, appropriate to the situation, argumentative, calm, confrontational, cooperative, depressed,

fidgety, flat, frustrated, fussy, happy, labile, manic, manipulative, normal, overly happy, pleasant, quiet, sad, stressed, tearful, tense, tired, uncomfortable].

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Cardiovascular:

Skin temperature is [OPTION=warm to cool proximal to distal*,cool to cool prox imal to distal, warm to

warm proximal to distal] on the right foot and [warm to cool proximal to distal*, cool to cool proximal

to distal, warm to warm proximal to distal] on the left foot.

Dorsalis pedis pulses are [OPTION=0/4, 1/4, 2/4, 3/4, 4/4, non-palpable, palpable, diminished, absent, bounding] left and [0/4, 1/4, 2/4, 3/4, 4/4, non-palpable, palpable, diminished, absent, bounding] right.

Posterior tibial pulses are [OPTION=0/4, 1/4, 2/4, 3/4, 4/4, non-palpable, palpable, diminished, absent, bounding] left and [0/4, 1/4, 2/4, 3/4, 4/4, non-palpable, palpable, diminished, absent, bounding] right.

Capillary fill time is [OPTION=< 3 seconds, 3-5 seconds, >5 seconds, delayed, immediate*] left and

[OPTION=< 3 seconds, 3-5 seconds, >5 seconds, delayed, immediate*] right.

[No*, pitting, +1, +2, +3, +4] edema is present [OPTION=right lower extremity, left lower extremities, bilateral lower extremities*].

Varicosities [OPTION=are, are not*] noted to [OPTION=right lower extremity, left lower extremities, bilateral lower extremities*].

Skin:

Skin color is noted to be [normal*, within normal limits, cyanotic, reddened, dark].

Skin texture is noted to be [normal*, healthy appearing, WNL, thin, dry, atrophic]

Examination of [hotspots] reveals [painful, erythematous, hyperkeratotic] area with evidence of [a dark

object, glass] present within the [superficial skin, dermis, epidermis]. The area [does not appear to be

infected, appears to be infected with associated purulent drainage, appears to be infected with associated cellulitis].

Neurological:

Vibratory sensation is [absent, diminished, present*] for left foot and [absent, diminished, present*] for right foot.

Sharp-dull sensation is [absent, diminished, present*, excessive] for left foot and [absent, diminished,

present*, excessive] for right foot.

Light touch sensation is [absent, diminished, present*] for left foot and [absent, diminished, present*] for right foot.

Deep tendon reflexes are [OPTION=absent, diminished, normal*].

Coordination is [OPTION=good*, fair, poor]

Musculoskeletal:

Muscle strength of extremities is [normal*, diminished left, diminished right].

15

Manual muscle testing is [OPTION=1, 2, 3, 4, 5] out of 5 for all groups.

Impression:

Plan:

Patient was instructed on lukewarm water soaks with Epsom salts bid x 3 days and apply dressing changes daily.

X-rays taken and reviewed

I&D of foreign body

Figure 3 - Screw Foot and Flip-Flop Sandal

Hyperkeratosis- Initial Patient: [Patient.Name] Account No: [Patient.AcctNo] Date: [Date]

Chief Complaint: This [Patient.Age] year old [Patient.Gender] presents today with a complaint of a [new

onset, chronic, tender, painful] callous formation beneath the [first, second, third, fourth, fifth] [right,

16

left] metatarsal head with pain upon [standing, walking, exercise, performing work duties, barefoot

walking, closed-toe shoe gear, and even when off weight-bearing]. The condition has been present for

[days, weeks, months, years] and recently is [worsened, the same, improved]. She has attempted [self-

debridement, soaks, lotions, OTC padding, shoe gear changes] which [have, have not] provided

relief. Patient [has, has not] had a similar condition previously. She [admits, denies] any recent trauma

or inciting events. She [has, has not] noted any drainage or bleeding from the area. She [admits, denies] a history or poor circulation or loss of protective sensation in the feet.


Medications: [Meds]



Past Family and Social History: [PFH] [Social History]

Review of Systems:


ENMT: [ENMT]

Cardiovascular: [CV]


GI: [GI]

GU: [GU]



Hematologic/Lymphatic: [Hematologic/Lymphatic]





Examination: The patient is appropriately dressed, articulate, awake, alert, and oriented x 3, appears

their stated age and appears to be in good health. Their vitals are as follows: [Vitals].

17

Vascular: Dorsalis pedis pulses are [0, 1, 2, 3, 4]/4 left and [0, 1, 2, 3, 4]/4 right. Posterior tibial pulses are

[0, 1, 2, 3, 4]/4 left and [0, 1, 2, 3, 4]/4 right. Capillary refill time with the leg elevated is [<3, 3, >3]

seconds at the level of the digital tufts bilaterally. There are no ischemic skin changes evident in either lower extremity. Edema [is, is not] noted in the [right, left, either, both] [foot, feet, ankle, leg].

Musculoskeletal: There is pain on palpation of the plantar aspect of the [first, second, third, fourth, fifth]

[right, left] metatarsal where a hyperkeratotic lesion is evident. The associated toe [is, is not]

contracted at the [MTPJ, PIPJ, DIPJ]. The contracture is [mild, moderate, severe] and is [rigid, semi-rigid,

reducible] at the [PIPJ, DIPJ] with [mild, moderate, severe] dorsiflexion contracture evident at the MTPJ

which is [reducible, semi-rigid, rigid]. EHL tendon contracture [is, is not] significant. The associated digit

is stable to modified Lachman test and there [is, is no] pain on palpation of the plantar plate. There are no other significant foot or ankle deformities appreciated bilaterally.

Neurological: Deep tendon reflexes including Achilles and Patellar are normal, brisk, and symmetrical

bilaterally. Epicritic sensation including sharp-dull, light touch, proprioception, 2-point discrimination (<

12 mm at level of hallux tuft), vibration (128 MHz tuning fork) and protective threshold (10.0 gram

monofilament) are intact. No focal motor or sensory deficits noted in either lower extremity. There are

down-going toes and a negative clonus bilaterally. Normal muscle mass is appreciated in both lower

extremities including the feet. Negative Mulder`s sign to the interspaces of both feet. Pain perception is

normal on palpation of the hyperkeratotic lesion and associated toe.

Dermatological: There is a deep seated hyperkeratotic lesion underlying the [right, left] [1st, 2nd, 3rd,4th

,5th] metatarsal head which, after debridement, [does, does not] reveal any verruca-type tissue,

characteristics of malignancy, evidence of foreign bodies or granulomas, or cardinal signs of infection.

Comprehensive review and inspection of the integument of both lower extremities [reveals, reveals no]

evidence of edema, erythema, ecchymosis, open lesions, interdigital maceration or signs of bacterial or

fungal infection. No varicosities, telangectasias, pigmented lesions or signs of venous stasis changes

noted in either lower extremity. [Adequate, Inadequate] fat padding to the inferior aspect of each foot appreciated.

Impression: Symptomatic lesser metatarsal deformity [left foot, right foot, both feet] producing a

chronic painful benign hyperkeratotic lesion and difficulty ambulating. No evidence of ulceration,

infection, foreign body, or suspicious skin changes were noted.

Treatment: I have discussed the treatment options with the patient and have [debrided the lesion full

thickness, dispensed some silicone padding which patient will reapply on a daily basis, recommended

use of Vaseline or similar product to decrease friction, stretched shoes, instructed patient to purchase

wider and extra-depth shoes with a low heel and stiff sole as well]. [I dispensed soft accommodative

insoles to cushion and cradle the deformity]. Discussed and recommended more permanent custom

orthotic devices should the accommodative measures applied today provide adequate relief of

symptoms. If these conservative measures fail to relieve symptoms, I briefly advised the patient of the

surgical options available to correct the underlying metatarsal deformity. I will discuss those options in

greater detail with the patient in the future if non-surgical treatments fail to provide long-term

satisfactory relief of symptoms.

RTC on a PRN basis for follow up care if the pain persists or worsens. RTC ASAP if problems such as increasing pain, redness, swelling, or drainage are noted, or other problems arise.

18

Hyperkeratosis - Follow-up


Subjective: Patient presents today for follow-up of a recurrent and chronic callous formation underlying

a lesser metatarsal deformity with pain associated with closed-toed shoe gear. Patient did well with the

debridement and padding but have noticed a significant recurrence of the callous formation and discomfort even with the changes in shoe gear and padding.

PMH, PSH, Medications: Unchanged since last visit.

Objective: The patient's neurovascular status of bilateral lower extremity is unchanged since last visit.

Musculoskeletal: There is pain on palpation of the plantar [first, second, third, fourth, fifth] [right, left]

metatarsal head where a hyperkeratotic lesion is evident. The metatarsal continues to be elongated and

plantar displaced compared to the adjacent metatarsals. There are no other significant foot or ankle deformities appreciated bilaterally.

Dermatological: There is a deep seated hyperkeratotic lesion plantar to the [first, second, third, fourth,

fifth] [right, left] metatarsal head of the [right, left, bilateral] foot which after debridement does not

reveal any verruca-type tissue, retained foreign bodies, or cardinal signs of infection. Otherwise, there is

no evidence of edema, erythema, ecchymosis, open lesions, interdigital maceration or signs of bacterial

or fungal infection of bilateral lower extremities. No varicosities, telangectasias, pigmented lesions or

signs of venous stasis changes bilateral lower extremities. Adequate fat padding to the inferior aspect of each foot appreciated.

Assessment: Symptomatic lesser metatarsal deformity [right, left, bilateral] foot.

Plan: I have discussed the previous the treatment options with the patient and have debrided the lesion

full thickness. Recommended continued use of the padding and insoles dispensed at previous visit,

recommended use of Vaseline or similar product to decrease friction, and have again stretched their

shoes. Since patient has not realized significant long-term benefit from these conservative measures I

recommended a metatarsal osteotomy to correct the condition. They have been advised of the

approximate disability involved for these procedures. In addition, the patient has been advised as to the

alternatives of care, including continued conservative care as well as surgical procedures. The patient

understands that if surgical procedures are performed, there are risks and complications that could

occur, including but not limited to: hematoma formation, seroma formation, development of a DVT or

phlebitis, infection, painful scar tissue formation, limited motion, delayed union, nonunion, malunion,

reaction to implanted biomaterials, over-correction, under correction with recurrence of the

deformities, continued pain, and the possibility that future surgery may nee d to be performed. The

patient was given the opportunity to ask questions which were answered to the best of my ability. The patient voiced no concerns and will consider all these options and schedule accordingly.

19

Hyperkeratosis Debridement

Hyperkeratotic [lesion was*, lesions were] debrided this date. Patient noted reduced pain and improved ambulation following the procedure.

Incision & Drainage – Established Patient Patient: [Patient.Name] Account No: [Patient.AcctNo] Date: [Date]

Chief Complaint: This [Patient.Age] year old [Patient.Gender] presents today with a complaint of an

ingrown [right, left] [hallux, 1st toe, 2nd toe, 3rd toe, 4th toe, 5th toe, foot, ankle, leg]. States the

problem is [acute, chronic]. The patient admits to [odor, redness, swelling, drainage, pain associated

with closed-toe shoe gear, nail coming loose]. Previous treatments: [self-debridement, soaks, local

wound care, surgical procedures, evaluation by another physician and referral to Podiatry]. Patient

states this problem a Review of Systems e from [an unknown cause, pedicure, trauma, improper cutting of nails].


Medications: [Meds]

Review of Systems:

Constitutional symptoms: [Constitutional]




Vitals: [Vitals]


stated age and looks to be in good health.

Dermatological: The [right, left] [1st digit, 2nd digit, 3rd digit, 4th digit, 5th digit, foot, ankle, leg] [medial

border, lateral border, entire nail plate] is [erythematous, edematous, hot, with purulent drainage, with

serosanginous drainage, with no drainage, incurvated at the nail fold, hypertrophied at the nail

labia]. Otherwise, no open lesions or signs of bacterial or fungal infection to the remainder of either foot.

Vascular: Dorsalis pedis and posterior tibial pulses are [0, 1, 2, 3, 4]/4 bilateral. Capillary filling time with

the leg elevated is [<5, 5,>5] seconds at the level of the digital tufts bilaterally. There [are, are not]

ischemic skin changes evident.

20

Impression: [abscess, ingrown toenail, sub-ungal ulcer, cellulitis]

Treatment: I have discussed the treatment options with the patient and due to the infected nature of

the area I recommended an incision and drainage with removal of all infected tissue. I discussed the

risks, complications, and expected recovery course with the patient and they understand the nail margin

will regrow and may become symptomatic again in the future. After obtaining appropriate informed

consent and verifying the correct digit, the toe was [anesthetized with 3cc of a half and half solution of

0.5% Marcaine™ plain and 1% lidocaine plain after which the digit was] prepped and draped in the usual

aseptic manner. Verification of anesthesia was performed. [A tourniquet was applied to the toe for 10

minutes]. The [area was incised and drained, offending nail border was removed and irrigated with

hydrogen peroxide]. Pus [was, was not] expressed. Bacitracin and a dry sterile dressing was applied.

[The tourniquet was removed]. Explicit oral and written postoperative instructions were dispensed. We will see the patient in follow-up in [11 days, 1 week, 2 weeks, prn].

Incision & Drainage –New Patient


Chief Complaint: This [Patient.Age] year old [Patient.Gender] presents today with a complaint of [an

ingrown nail, an infected toenail, a painful nail, an abscess, a red area] of the [right, left, bilateral]

[hallux, 2nd toe, 3rd toe, 4th toe, 5th toe, foot, leg]. States the problem is [acute, chronic, been present

for a while but thought it would resolve on its own]. The patient admits to [odor, redness, clear

drainage, pus draining, pain associated with closed-toe shoe gear, burning, heat, pain]. Previous

treatments: [antibiotics prescribed by another physician, self-debridement, soaks, local wound care,

surgical procedures, nothing as it is too painful to touch, benign neglect]. Patient states this problem

arose from [an unknown cause, pedicure, trauma, improper cutting of nails, improperly fitted shoes, trauma, swelling of the legs and feet].


Medications: [Meds]



Past Family and Social History: [PFH]; [Social History]

Review of Systems:


ENMT: [ENMT]

21



GI: [GI]

GU: [GU]











border, lateral border, entire nail plate] is [erythematous, edematous, with purulent drainage, with

serosanginous drainage, with no drainage, incurvated at the nail fold, hypertrophied at the labial nail,

with granulomatous lesion, loose from the nail bed partially, loose from the nail bed completely]. [No open lesions or signs of bacterial or fungal infection to the remainder of either foot].

Neurological: Protective sensation [intact, diminished, absent]. Pain [is, is not] appreciated to the area.


the leg elevated is [<5, 5, >5] seconds at the level of the digital tufts bilaterally. There [are, are not]

ischemic skin changes evident.

Musculoskeletal: [Muscle strength for all prime movers of the foot are intact bilateral with appropriate

muscle tone and symmetry and full range of motion for all joints without crepitation or instability

appreciated, muscle weakness appreciated as a result for medical status, limitation of motion and

stiffness appreciated as a result of current medical condition].

Impression: [paronychia, severe abscess, symptomatic ingrown toenail, sub-ungal ulcer, granuloma,

hematoma, seroma, ulceration, subungual ulcer, cellulitis] [1R, 2R, 3R, 4R, 5R, 1L, 2L, 3L, 4L, 5L, right foot, right leg, left foot, left leg][medial border, lateral border, entire nail plate]

Plan: I have discussed the treatment options with the patient and due to the nature of the infection, I

recommended a [slant back procedure, incision and drainage with removal of all infected tissue and the

nail margin, permanent removal of the nail margin to prevent future complications, removal of loose

nail plate, chemical cauterization of the granuloma, incision and drainage of wound, monitoring the for

22

improvement]. I discussed the risks, complications, and expected recovery course with the patient and they understand the area may become symptomatic again in the future.

Treatment: Appropriate informed consent was obtained and verification of the correct digit was done.

[The toe was anesthetized with 3cc of a half and half solution of 0.5% Marcaine ™ plain and 1% lidocaine

plain, No anesthesia was required as the patient was insensate enough to tolerate the procedure, the

digit was prepped in the usual aseptic manner]. A tourniquet was [applied to the digit , applied to the

ankle, not applied]. [The offending nail border was removed along with all granulomatous and

devitalized tissue and then the wound was irrigated with hydrogen peroxide and dressed with bacitracin

and a dry sterile dressing, 3 applications of phenol (89% Carbolic Acid) at 30 seconds each were applied

via micro tip cotton applicator then the area was irrigated with isopropyl alcohol. The digit was sprayed

with hydrogen peroxide solution which discolors the phenol in an effort identify and remove inadvertent

contact of the phenol with normal skin. Amerigel® was applied to the wound to neutralize the phenol,

the nail plate was freed from the nail bed and the wound was dressed with bacitracin and a non-

adherent dressing, the granulomatous lesion was debrided with silver nitrate, the granulomatous lesion

was debrided by way of sharp excision, the area was incised and drained of all pus and fluid

accumulations creating a healthy wound base and irrigated with NSS]. A lightly compressive dressing

was applied with a protective outer dressing. [The tourniquet was removed]. Explicit oral and written

postoperative instructions were dispensed. We will see the patient in follow-up in [1 week, 11 days, 2 weeks, prn]. Should problems arise patient agrees to come to the office for evaluation.

Ingrown Nail – Follow-up


Subjective: Patient returns 2 weeks since undergoing a nail margin procedure on [right, left, bilateral]

[1st, 2nd, 3rd, 4th, 5th] digit. Patient has been doing very well since last visit and has been very

compliant with postoperative instructions, soaking BiD with Q-tip cleansing of the offending nail margin,

use of topical antibiotics, bandage coverage, and use of open-toe shoe gear as much as possible. The

patient denies any fever, chills, nausea or vomiting, calf pain or tenderness, shortness of bre ath, chest pain, and local or systemic signs of infection.

Objective: No change from the previous musculoskeletal examination of bilateral lower extremity. The

offending nail margin is [clean and dry and intact with no evidence of early recurrence, draining

serosanginous fluid, draining purulent fluid, erythematous]. There is no pain on palpation of the offending nail margin.

Assessment: status post nail procedure [1, 2, 3, 4, 5] [right, left] [doing well, unchanged, worsening].

Plan: I cleansed the toenail margin for the patient and recommended [discharge from care as wound is

healed, continued use of topical antibiotics and bandage application, use of an open-toe shoe whenever

possible, daily soaks until a stable eschar has formed]. I will see patient back on a [PRN basis, in 1 week,

in 2 weeks] and have cautioned patient regarding nail regrowth and/or recurrence.

23

Figure 4 - Healing Progression of Postoperative Ingrown Toenail

Kissing corn


Subjective: Patient presents today for follow-up of a recurrent and chronic callous formation between

the toes in the [1st, 2nd, 3rd, 4th] innerspace of the [right, left] foot. This is associated with pain in

closed-toed shoe gear. Patient did well with the debridement and padding but have noticed a

significant recurrence of the callous formation and discomfort even with the changes in shoe gear and

padding.



Musculoskeletal: There [is, is not] pain on palpation of the [1st, 2nd, 3rd, 4th] webspace of the [right,

left] foot where a hyperkeratotic lesion is evident. There are no other significant foot or ankle

deformities appreciated bilaterally.

24

Dermatological: There is a deep seated hyperkeratotic lesion in the webspace which after debridement

does not reveal any verruca-type tissue, retained foreign bodies, or cardinal signs of infection.

Otherwise, there is no evidence of edema, erythema, ecchymosis, open lesions, interdigital maceration

or signs of bacterial or fungal infection of bilateral lower extremities. No varicosities, telangectasias,

pigmented lesions or signs of venous stasis changes bilateral lower extremities. Adequate fat padding to

the inferior aspect of each foot appreciated.

Radiographs: Reveal [no gross bony abnormalities, hypertrophic condyle adjacent to the lesion, underlapping digit adjacent to the lesion].

Assessment: Symptomatic heloma molle [1st, 2nd, 3rd, 4th] innerspace of the [right, left] foot.

Plan: I have discussed the treatment options with the patient and have debrided the lesion full

thickness. Recommended continued use of the padding and insoles dispensed at previous visit,

recommended use of Vaseline or similar product to decrease friction, and have again stretched their

shoes. Since patient has not realized significant long-term benefit from these conservative measures I

recommended a procedure to correct the condition. The recommended procedure is [percutaneous

osteotripsy, arthroplasty, exostectomy, ostectomy, partial saucerization] of the involved phalanges of

the [right, left] [1st, 2nd, 3rd, 4th, 5th] digits. They have been advised of the approximate disability

involved for these procedures. In addition, the patient has been advised as to the alternatives of care,

including continued conservative care as well as surgical procedures. The patient understands that if

surgical procedures are performed, there are risks and complications that could occur, including but not

limited to: hematoma formation, seroma formation, development of a DVT or phlebitis, infection,

painful scar tissue formation, limited motion, delayed union, nonunion, malunion, reaction to implanted

biomaterials, over-correction, under correction with recurrence of the deformities, continued pain, and

the possibility that future surgery may need to be performed. The patient was given the opportunity to

ask questions which were answered to the best of my ability. The patient voiced no concerns and will

consider all these options and schedule accordingly.

Figure 5 - Soft Kissing Corn

25

Lesion Description

Lesion is surface is described as [pigmented black, pigmented brown, pigmented blue, homogenous in

color, heterogeneous in color]. The surface is [flat, nodular, raised, waxy]. The texture is [dry, inflamed,

moist, peeling, scaling, supple, ulcerated]. Measures [1,2,3,4,5,6,7,8,9,10] [mm, cm, inches] long by [1 ,

2, 3, 4, 5, 6, 7, 8, 9, 10] [mm, cm, inches] wide. The borders are described as [regular, irregular, not well defined, well defined, serpintiginous, rolled, hyperkeratotic]. [hotspots].

Nail Avulsion - Initial Patient: [Patient.Name] Account No: [Patient.AcctNo] Date: [Date] Provider: [Provider.Name]

Chief Complaint: Patient is a [Patient.Age] year old [Patient.Gender] who presents today with complaint

of painful [ingrown, thickened, loosened] nail, on [right, left, bilateral] [1, 2, 3, 4, 5] toe which has had

some slight odor, slight redness, clear drainage, and pain associated with closed-toe shoe gear and has

not responded to self-debridement, soaks, and local wound care. The problem has been present for [days, weeks, months]. Patient is interested in treatment options.


Medications: [Meds]





Review of Systems:


Eyes: [Eyes]

Ears, Nose, Mouth, Throat: [ENMT]



GI: [GI]

GU: [GU]

26







Allergic/Immunologic: [Immunologic]

Physical Examination: The patient is appropriately dressed, articulate, awake, alert, and oriented x 3,

appears stated age and looks to be in good health.

[Vitals]

Dermatological: There is erythema and edema but no purulent drainage, and an associated [incurvated,

thickened, loosened] nail with hypertrophied labial nail fold appreciated to the offending [right, left,

bilateral] [medial border, lateral border, medial and lateral borders, entire] [1st, 2nd, 3rd, 4th, 5th] nail. No

proximal cellulitis or deep abscess evident at this time. Otherwise, no open lesions or signs of bacterial or fungal infection to the remainder of either foot.

Neurological: Pain is appreciated to the offending [right, left, bilateral] [medial, lateral, both medial and

lateral] nail border of the great toe. Deep tendon reflexes including Achilles and Patellar are normal,

brisk, and symmetrical bilateral. Epicritic sensation including sharp-dull, light touch, proprioception, 2-

point discrimination (< 12 mm at level of hallux tuft), vibration (128 MHz tuning fork) and protective

threshold (10.0 gram monofilament) are intact and without focal motor or sensory deficit bilateral lower

extremities. There are down going toes and a negative clonus bilateral. Normal muscle mass appreciated

to both the lower extremity and foot bilateral. The patient can heel and toe walk with ease as well as arise from a seated position unassisted.

Vascular: Dorsalis pedis and posterior tibial pulses are [0, 1, 2*, 3, 4]/4 bilateral. Capillary filling time

with the leg is [<3*, 3, >3] seconds at the level of the digital tufts bilateral. There are no ischemic skin changes evident in bilateral lower extremities.

Musculoskeletal: Proper alignment to the lower legs, stable ankle to manual stress (inversion and

anterior drawer), hind foot, mid foot and forefoot bilateral lower extremities. Muscle strength for all

prime movers of the lower leg, ankle, and foot are graded at 5/5 bilaterally. Appropriate muscle tone

and symmetry of bilateral lower extremities. Full, fluid range of motion for all joints from the ankle joint distal without crepitation or instability appreciated in bilateral lower extremities.

Impression: [Onychocryptisis, Onychomycosis, Onycholysis] [with, without] paronychia, [1st, 2nd, 3rd, 4th, 5th] toe [right, left, bilateral] [medial border, lateral border, bilateral borders, entire nail].

Treatment: Treatment options were discussed. At this time I recommended nail avulsion to the affected

digits. After appropriate consent and verifying the correct [digit, digits], the toe was anesthetized with 3

27

cc of 1:1 mixture of 0.5% Marcaine plain and 1% lidocaine plain. A tourniquet was applied to the toe(s).

The offending nail border(s) was avulsed. The tourniquet was removed after verifying that all pathologic

nail tissue was removed, and an antibiotic-impregnated compression dressing applied to the toe itself.

Explicit oral and written postoperative instructions were dispensed. We will see the patient in follow up in two weeks’ time or sooner should problems arise.

[Provider.Name]

cc: [Referral.Name]

Nail Avulsion - Follow-up

Patient: [Patient.Name] Account No: [Patient.AcctNo] Date: [Date] Provider: [Provider.Name]

Subjective: Patient returns 2 weeks since undergoing a nail avulsion on [right, left, bilateral] [1st, 2nd, 3rd,

4th, 5th] digit. Patient has been doing very well since last visit and has been very compliant with

postoperative instructions, including soaks and dressing changes. The patient states the digit is [not

improved, mildly improved, greatly improved*]. Pt relates [no, mild*, moderate] drainage. The patient [has, has not] been taking oral antibiotics.

Objective: The patient is [intact, diminished] from a neurovascular standpoint. No change from the

previous musculoskeletal examination of bilateral lower extremity. The offending nail margin is healing

well with [wet*, dry] escar and [no, mild*, moderate] marginal erythema present. There is [no, mild*,

moderate] pain on palpation of the offending nail margin. [No, Mild*, Moderate] serous drainage

present.

Assessment: 2 weeks status post nail avulsion, [improving*, worsening, unchanged, resolved].

Plan: I cleansed the toenail margin for the patient and recommended continued use of topical

antibiotics, daily dressing changes, and soaks until the drainage has stopped, and until a stable eschar

has formed, at which point the above home care may be discontinued. The patient will follow up [2

weeks, 4 weeks, 10 weeks, PRN*]. I have cautioned patient regarding nail regrowth and/or

recurrence. Should the physical therapist notice any increased pain, swelling, redness or drainage they will contact the office immediately.

Onychomycosis - Established Patient


28

Subjective: Patient is a [Patient.Age] year old [Patient.Gender] who presents today [ambulating, in a

wheelchair, using a walker, using a cane] for evaluation and treatment of [onychomycosis, painful

mycotic nails, diabetic condition, podiatric condition]. The patient has been [using topical Clarus AF oil

on the nails, using NAFTIN cream on the nail bed(s) after nail removal, unable to perform self-nail care

due to the severe nature of nail deformities which cause limitation in ambulation due to pain and

pressure in shoe gear, having nails professionally done due to the diabetic risk factors associated with

attempted care]. Patient was last seen by Dr.[Dupuis, Holman, D.Freitas, P.Freitas, Flurry, Binkard, Willis,

Dunn, Rush, May, W. Willis, S. Willis, Osban, Tillery, Bumaget, Sarkoche, Snow, Garg, Pinkston, Mian,

Navas, Martin, Hoang, Messick, Kincaid, Kinselman, Johnson] on [1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12], [2009, 2010, 2011, 2012, 2013, 2014, 2015].

Objective: [Hotspots] are [improving proximally but still discolored distally, resolved in signs of

infection, elongated, thick, hypertrophic, crumbly, discolored, deformed, ridged, malodorous, lysing

with friable subungual debris which after debridement to underlying nail be d reveals a characteristic

fungal/yeast/mold odor and consistency]. There [is, is no] surrounding cellulitis. There [is, is no] deep

incurvation. There [is, is not] evidence of bacterial infection. [Review of the integument revealed no

wounds with infection nor ulcerations, the webspaces are macerated.] The neurovascular status is

unchanged as compared to previous examinations. No ischemia or cyanosis noted.

Assessment: Symptomatic onychomycosis with [improvement using topical treatments, improved using

oral treatment, marked limitation of ambulation, pain, a high likelihood of complications if not treated professionally on a regular basis].

Plan: [Mechanical and electrical debridement of the mycotic toenails was performed and the toenails

were reduced to as normal a thickness and length that patient tolerance would allow]. This was done on

[1-5, 6-10] nails. [This improved the texture, This greatly reduced the pain with pressure applied to the

nail plates]. [The patient's ability to ambulate was also observed to be improved following

debridement]. [Antifungal and antiseptic solution was applied to the nails]. Advised to [use AF nail oil,

use tea tree oil, use Lamisil, continue to use laser treatments, continue to use nail oil to prevent

recurrence, Onmel] to treat the fungal infection. The patient [does, does not] desire to treat the

infection.

Return to clinic [as needed, 10 weeks, 12 weeks, 6 months, one year].

29

Figure 6 - Proximal subungual onychomycosis (arrow)

Onychomycosis - New Patient


Chief Complaint: This [Patient.Age] year old [Patient.Gender] presents today for evaluation and

treatment of [painful, discolored, thick, loose, mycotic, elongated] nails. The patient [has been able, has

been unable, because of diabetes mellitus was advised by PCP not, because of use of blood thinners was

advised by pcp not] to provide self-nail care. [Due to the severe nature of deformity the nails cause

limitation in ambulation due to pain and pressure in shoe gear.] [Patient has attempted self-

debridement with limited success or has caused harm to themselves.] Patient was last seen by their PCP, [Patient.PrimaryPhysician] on [Patient.DateLastSeen].


Medications: [Meds]




30

Review of Systems:


ENMT: [ENMT]



GI: [GI]

GU: [GU]









their stated age and appears to be in good health. Their vitals are as follows: [Vitals]. The patient

appears [well, poorly] nourished and [well, poorly groomed], NAD.

Vascular: Dorsalis pedis are graded at [0/4 b/l, 1/4 b/l, 2/4 b/l, 3/4 b/l, 4/4 b/l, monophasic b/l, biphasic

b/l, triphasic b/l, 0/4 right, 0/4 left, 1/4 right, 1/4 left, 2/4 right, 2/4 left, 3/4 right, 3/4 left, 4/4 right, 4/4

left, monophasic left, bipasic left, triphasic left, monophasic right, biphasic right, triphasic right, ] and

posterior tibial pulses are graded at [0/4 b/l, 1/4 b/l, 2/4 b/l, 3/4 b/l, 4/4 b/l, monophasic b/l, biphasic

b/l, triphasic b/l, 0/4 right, 0/4 left, 1/4 right, 1/4 left, 2/4 right, 2/4 left, 3/4 right, 3/4 left, 4/4 right, 4/4

left, monophasic left, biphasic left, triphasic left] Digital hair growth [present, sparse, absent] bilateral.

CFT with the leg elevated was [less than 3 seconds, 3 seconds, more than 3 seconds] at the distal toes

bilateral. There [is, is not] evidence of ischemic skin changes. Temperature from the tibia to the toes is [warm, cool] at anterior tibia to [warm, cool] at the distal digits bilateral.

Neurological: [Coordination WNL to right and left lower extremity, Protective sensation grossly intact, Protective sensation diminished.]

Dermatological: [Hotspots] is [mildly, severely, elongated, thickened, yellow/discolored, crumbly, ridged,

lysing with friable subungual debris]. There is [surrounding cellulitis, deep incurvation of nail(s),

evidence of surrounding bacterial infection, evidence of surrounding fungal infection, evidence of

chronic picking at the nail and ungal labia, abscess of nail(s), no pathologic skin changes]. Class findings

31

include [absent (0/4), diminished (1/4), normal (2/4), strong (3/4), bounding (4/4)] pedal pulses

[bilaterally, unilaterally] [normal, diminished, absent] digital/pedal hair growth, [no, mild, moderate,

severe] telangectasias and [no, mild, moderate, severe] lower leg edema. At risk areas are [present, absent]. Open ulcerations are [absent, present].

Musculoskeletal: Patient is [able to walk, able to walk with a walker, able to walk with a cane, in a

wheelchair]. [Stable foot posture without obvious structural deformities noted bilateral, Forefoot and

digital malposition in foot structure, Midfoot malposition in foot structure, Rearfoot structural

malposition, Ankle foot structure malposition]. Muscle strength of the lower extremity shows [normal,

weak, absent] primary movers. [Stiff contracted joints present., Fluid range of motion for all joints from

the ankle to the distal toes without crepitation noted bilateral., Range of motion of joints is limited.]

Assessment: Symptomatic onychomycosis [tinea pedis, tinea interdigitus, onychocryptosis, ingrown toenail]

Plan: The offending nail plates and margins were mechanically and electrically debrided [1-5, 6-10] in as

normal thickness and length as the patient would tolerate. This rendered the patient asymptomatic with

applied pressure to the nail plate. [This was also evidenced by pain free ambulation]. Antifungal and

antiseptic solution was applied to the nails. Recommend patient consider options of treatment to

include:[Clarus™ topical oil, Penlac® topical agent, OTC AF therapy, prescription strength AF therapy,

laser treatment, oral antifungal therapy] on the toenails to attempt to treat the fungal infection. At this

point the patient elects to use [Clarus™ topical oil, Penlac® topical agent, OTC AF therapy, prescription

strength AF therapy, laser treatment, oral antifungal therapy]. Instructed to wash socks in bleach as well as the bed sheets. Also instructed to spray shoes with AF spray every night and let dry overnight.

Return to clinic [as needed, 10 weeks, 12 weeks, 6 months, 12 months].

Phenol and Alcohol Matrixectomy

Treatment: I have discussed the treatment options with the patient and due to the painful nature of the

toe and severe incurvated nail edge present I recommend permanent removal of the [entire toenail,

medial border of toenail, lateral border of toenail]. I discussed the risks, complications, and expected

recovery course with the patient and they understand the nail, nail margin, or spicules of it, may re -grow

and may become symptomatic again in the future. After appropriate consent and verifying the correct

digit, an injection was performed using [1, 2, 3*, 4, 5]cc of a 1:1 mix of 1% Lidocaine and 0.5%

Marcaine™ after which it was prepped and draped in the usual aseptic manner. Verification of

anesthesia was performed after which a tourniquet was applied to the toe. Upon proper anesthesia, the

[entire toenail, medial border of toenail, lateral border of toenail, medial and lateral borders of the

toenail] was freed from its soft tissue attachments and excised in toto. Area was inspected for spicules

and none were found. 3 applications of phenol (89% Carbolic Acid) applied, for 30 seconds each and the

area irrigated with alcohol. The digit was sprayed with hydrogen peroxide solution which discolors the

phenol in an effort identify inadvertent burning of normal skin. Amerigel ® was applied and a lightly

compressive non-stick sterile dressing. The tourniquet was removed. A prompt hyperemic response was

noted to the toe. Explicit oral and written postoperative instructions were dispensed describing the

post-operative care of the site. We will see the patient in follow up in two weeks’ time if needed or sooner should problems arise.

32

Phenol and Alcohol Matrixectomy – Established Patient



of chronic ingrown nail on [right, left, bilateral] [great, 2nd, 3rd, 4th, 5th] toe with [odor, erythema, clear

drainage, cloudy drainage, pain with closed toed shoes] and [has, has not] responded to self -

debridement, soaks, and local wound care. Patient has had a similar condition previously treated

[conservatively, surgically, with debridement] and desires to have a permanent procedure so the nail edge will not grow back.


Medications: [Meds]

Review of Systems:






Physical Examination: The patient is appropriately dressed, articulate, awake, alert, and oriented x 3, appears stated age and looks to be in good health.

Dermatological: There is [erythema, edema, pus, clear drainage] and an associated incurvated nail with hypertrophied labial nail fold appreciated to the offending nail border.


the leg elevated is [<5, 5, >5] seconds at the level of the digital tufts bilateral. There are no ischemic skin

changes evident in bilateral lower extremities.

Impression: Chronic onychocryptosis [1, 2, 3, 4, 5] [right, left, bilateral] [medial border, lateral border, medial and lateral borders, entire nail].

Treatment: I have discussed the treatment options with the patient and due to the chronic nature

patient elects to have the above nail(s) removed permanently. I discussed the risks, complications, and

expected recovery course with the patient and they understand the nail margin, or spicules of it, may re -

grow and may become symptomatic again in the future. After appropriate consent and verifying the

correct digit(s), the toe was anesthetized with 3 cc of 0.5% Marcaine™ plain, after which it was prepped

33

and draped in the usual aseptic manner. Verification of anesthesia was performed after which a

tourniquet was applied to the toe. The offending nail border was removed, 3 applications of phenol

(89% Carbolic Acid) applied, and the area irrigated with alcohol. The digit was sprayed with hydrogen

peroxide solution which discolors the phenol in an effort to identify inadvertent burning of normal skin.

Amerigel® was packed in the wound and a lightly compressive dry sterile dressing was applied. The

tourniquet was removed. Explicit oral and written postoperative instructions were dispensed. We will see the patient in follow up in two week’s time or sooner should problems arise.

Phenol and Alcohol Matrixectomy – New Patient



of chronic ingrown nail on [right, left, bilateral] [great, 2nd, 3rd, 4th, 5th] toe. Admits [pain, redness,

drainage, odor, infection, pain in shoe gear] and has not responded to self-debridement, soaks, and local

wound care. Previous treatments: [no treatment, local wound care, debridement, surgical procedures, soaks]. [Patient desires to have a permanent procedure so the nail edge will not grow back].


Medications: [Meds]




Review of Systems:


ENMT: [ENMT]



GI: [GI]

GU: [GU]



34






Examination: The patient is [appropriately dressed, articulate, awake, alert, and oriented x 3] Patient

appears to be in [good, fair, poor, neglected] health. Vitals are as follows: [Vitals].

Dermatological: There is [erythema and edema, purulent drainage, incurvated nail with hypertrophied

labial nail fold, no signs at this time as the nail is quiescent] appreciated to the offending [right, left,

bilateral] [medial, lateral, medial and lateral] [hallux*, 2nd, 3rd, 4th, 5th] nail border(s). [Proximal cellulitis,

distal cellulitis, deep abscess] evident.

Neurological: Pain [is*, is not] appreciated to the offending nail border(s). Epicritic sensation appears

[intact, absent]. The patient [can heel and toe walk with ease, arise from a seated position unassisted, cannot walk].


the leg elevated is [<3, 3, >3] seconds at the level of the digital tufts bilateral. There [are, are no] ischemic skin changes evident in bilateral lower extremities.

Impression: Chronic onychocryptosis [1, 2, 3, 4, 5] [right, left, bilateral] [medial, lateral, medial and lateral] border(s).

Treatment: I have discussed the treatment options with the patient and due to the chronic nature of

the toenail and severe incurvated nail edge present I recommended a removal of the nail margin(s) and

all infected tissue. I discussed the risks, complications, and expected recovery course with the patient

and they understand the nail margin, or spicules of it, may re-grow and may become symptomatic again

in the future. After appropriate consent and verifying the correct digit, the toe was anesthetized with 3

cc of a 50/50 mixture of 0.5% Marcaine™ and 1% lidocaine plain after which it was prepped and draped

in the usual aseptic manner. Verification of anesthesia was performed after which a tourniquet was

applied to the toe. The offending nail border(s) was removed, 3 applications of phenol (89% Carbolic

Acid) applied, and the area irrigated with alcohol. The digit was sprayed with hydrogen peroxide solution

which discolors the phenol in an effort identify inadvertent burning of normal skin. Amerigel ® was

applied and a lightly compressive dry sterile dressing. The tourniquet was removed. Explicit oral and

written postoperative instructions were dispensed. The patient was given options to either use

Amerigel® twice daily with dressing changes or soak the toe in Epsom salts 3 times daily for ten minutes

each time after which apply a dry sterile dressing. Patient was advised to take a pain reliever of their

choice as needed. We will see the patient in follow up in 11-14 day’s time or sooner should problems arise.

35

Figure 7 – Phenol portion of Matrixectomy

Partial Nail Avulsion – New Patient


Chief Complaint: This [Patient.Age] year old [Patient.Gender] presents today with a complaint of [an

ingrown nail, an infected toenail, a painful nail, an abscess, a red area] of the [right, left, bilateral]

[hallux, 2nd toe, 3rd toe, 4th toe, 5th toe, foot, leg]. States the problem is [acute, chronic, been present for

a while but thought it would resolve on its own]. The patient admits to [odor, redness, clear drainage,

pus draining, pain associated with closed-toe shoe gear, burning, heat, pain]. Previous treatments:

[antibiotics prescribed by another physician, self-debridement, soaks, local wound care, surgical

procedures, nothing as it is too painful to touch, benign neglect]. Patient states this problem arose from

[an unknown cause, pedicure, trauma, improper cutting of nails, improperly fitted shoes, trauma, swelling of the legs and feet].


36

Medications: [Meds]




Review of Systems:


ENMT: [ENMT]



GI: [GI]

GU: [GU]








Examination: The patient is appropriately dressed, articulate, awake, alert, and oriented x 3, appears their stated age and appears to be in good health. Their vitals are as follows: [Vitals].


border, lateral border, entire nail plate] is [erythematous, edematous, with purulent drainage, with

serosanginous drainage, with no drainage, incurvated at the nail fold, hypertrophied at the labial nail,

with granulomatous lesion, loose from the nail bed partially, loose from the nail bed completely]. [No open lesions or signs of bacterial or fungal infection to the remainder of either foot].

Neurological: Protective sensation [intact, diminished, absent]. Pain [is, is not] appreciated to the area.


the leg elevated is [<5, 5, >5] seconds at the level of the digital tufts bilaterally. There [are, are not] ischemic skin changes evident.

37

Musculoskeletal: [Muscle strength for all prime movers of the foot are intact bilateral with appropriate

muscle tone and symmetry and full range of motion for all joints without crepitation or instability

appreciated, muscle weakness appreciated as a result for medical status, limitation of motion and stiffness appreciated as a result of current medical condition].

Impression: [paronychia, severe abscess, symptomatic ingrown toenail, sub-ungal ulcer, granuloma,

hematoma, seroma, ulceration, subungual ulcer, cellulitis] [1R, 2R, 3R, 4R, 5R, 1L, 2L, 3L, 4L, 5L, right

foot, right leg, left foot, left leg][medial border, lateral border, entire nail plate]

Plan: I have discussed the treatment options with the patient and due to the nature of the infection, I

recommended a partial nail avulsion of the offending nail segment with removal of all infected tissue

and hypertrophic tissue in the nail groove. I discussed the risks, complications, and expected recovery

course with the patient and they understand the area may become symptomatic again in the future.

Treatment: Appropriate informed consent was obtained and verification of the correct digit was done.

[The toe was anesthetized with 3cc,4cc,5cc,6cc of, a half and half solution of 0.5% Marcaine ™ plain and

1% lidocaine plain,2% lidocaine plain, No anesthesia was required as the patient was insensate enough

to tolerate the procedure, The digit was prepped in the usual aseptic manner]. [A digital tourniquet was

applied and removed at the end of the procedure, no tourniquet was applied]. A partial avulsion of the

offending segment of nail was performed and all granulomatous and devitalized tissue within the nail

fold was removed. The wound was then irrigated with hydrogen peroxide and dressed with bacitracin

and a dry sterile lightly compressive dressing was applied. [The patient was given a prescription for, The

patient was advised to discontinue the medication if side effects arise and to notify the office

immediately for adjustment of the antibiotics, Antibiotics were not deemed necessary.] [The

tourniquet was removed]. Explicit oral and written postoperative instructions were dispensed for daily

wound care. We will see the patient in follow-up in [1 week, 11 days, 2 weeks, prn] Should problems

arise earlier or signs and symptoms of infection worsen the patient agrees to come to the office for

evaluation.

Partially Avulsed Nail Patient: [Patient.Name] Account No: [Patient.AcctNo] Date: [Date]

Chief Complaint: This [Patient.Age] year old [Patient.Gender] presents today with a complaint of a

[acute, chronic] avulsing nail of the [right, left] [1st, 2nd, 3rd, 4th, 5th] digit which is painful and has not

responded to [self-debridement, soaks, local wound care]. Patient [has, has not] had a similar condition

previously. Patient states this problem arose from [pedicure, trauma, improper cutting of nails].


Medications: [Meds]


38



Review of Systems:


Eyes: [Eyes]




GI: [GI]

GU: [GU]









stated age and looks to be in good health.

Dermatological: The nail of the [right, left] [1st, 2nd, 3rd, 4th, 5th] digit is partially avulsed with [hematoma

under the nail plate, erythema, edema, drainage, odor]. Otherwise, no open lesions or signs of bacterial or fungal infection to the remainder of either foot.

Neurological: Pain is appreciated to the offending nail border. Deep tendon reflexes including Achilles

and Patellar are normal, brisk, and symmetrical bilateral. Epicritic sensation including sharp-dull, light

touch, proprioception, 2-point discrimination (< 12 mm at level of hallux tuft), vibration (128 MHz tuning

fork) and protective threshold (10.0 gram monofilament) are intact and without focal motor or sensory

deficit bilateral lower extremities. Normal muscle mass appreciated to both the lower extremity and foot bilateral.

Vascular: Dorsalis pedis and posterior tibial pulses of the effected foot are [0, 1, 2, 3, 4]/4 bilateral.

Capillary filling time with the leg elevated is [<5, 5,>5] seconds at the level of the digital tufts bilaterally. There are no ischemic skin changes evident to bilateral lower extremities.

39


anterior drawer), hindfoot, midfoot and forefoot bilateral lower extremities. Muscle strength for all

prime movers of the lower leg, ankle, and foot are graded at 5/5 bilateral lower extremities. Appropriate

muscle tone and symmetry bilateral lower extremities. Full, fluid range of motion for all joints from the ankle joint distal without crepitation or instability appreciated bilateral lower extremities.

Impression: [traumatic nail avulsion, ingrown toenail]

Treatment: I have discussed the treatment options with the patient and due to the infected nature of

the toe and severe incurvated nail edge present I recommended an incision and drainage with removal

of all infected tissue and the nail margin. I discussed the risks, complications, and expected recovery

course with the patient and they understand the nail margin will regrow and may become symptomatic

again in the future. After obtaining appropriate informed consent and verifying the correct digit, the toe

was anesthetized with 3cc of a half and half solution of 0.5% Marcaine™ plain and 1% lidocaine plain

after which the digit was prepped and draped in the usual aseptic manner. Verification of anesthesia

was performed after which a tourniquet was applied to the toe for 5-10 minutes. The offending nail

border was removed and irrigated with hydrogen peroxide. Bacitracin and a dry sterile dressing was

applied. The tourniquet was removed. Explicit oral and written postoperative instructions were dispensed.

Return to clinic as needed and if problems arise.

Pigmented Lesion


Chief Complaint: [Patient.FirstName] is a [Patient.Age] year old [Patient.Gender] who presents today

with a complaint of a chronic pigmented lesion which has not responded to soaks and OTC padding with

shoe gear changes. They [have, have not*] had a similar condition previously and deny any recent

trauma or inciting events. They do not have a family history of cutaneous malignancy and have not had any similar lesions on the remainder of their body treated at any time.


Medications: [Meds]




Review of Systems:

40


Eyes: [Eyes]




GI: [GI]

GU: [GU]








Physical Examination: The patient is appropriately dressed, articulate, awake, alert, and oriented x 3,

appears their stated age and appears to be in good health. Vascular: Dorsalis pedis and posterior tibial

pulses are readily palpable and graded at 2/4 bilateral. Capillary filling time with the leg elevated is <5

seconds at the level of the digital tufts bilateral. There are no ischemic skin changes evident of bilateral

lower extremities. Musculoskeletal: Normal strength, range of motion and alignment for all joints from

the ankle distal are evident bilateral. Neurological: Deep tendon reflexes including Achilles and Patellar

are normal, brisk, and symmetrical bilateral. Epicritic sensation including sharp-dull, light touch,

proprioception, 2-point discrimination (< 12 mm at level of hallux tuft), vibration (128 MHz tuning fork)

and protective threshold (10.0 gram monofilament) are intact and without focal motor or sensory deficit

bilateral lower extremities. There are downgoing toes and a negative clonus bilateral. Normal muscle

mass appreciated to both the lower extremity and foot bilateral. Dermatological: There is a raised

pigmented lesion to their foot/toe which does not show any cardinal signs of cutaneous malignancy or

significant irritation. Otherwise, there is no evidence of edema, erythema, ecchymosis, open lesions,

interdigital maceration or signs of bacterial or fungal infection bilateral lower extremities. No

varicosities, telangiectasias, or signs of venous stasis changes of bilateral lower extremities. Adequate

fat padding to the inferior aspect of each foot is appreciated.

Impression: Symptomatic pigmented lesion

41

Treatment: I have discussed the treatment options with the patient and have recommended use of

Vaseline or similar product to decrease friction and either purchasing wider, extra-depth shoe gear or

stretching their current shoes. Should these measures fail I recommended a simple excision of the

lesion under local anesthesia and discussed the risks, complications, and expected recovery course in

detail. They will monitor the lesion and look for patriotic signs of change (i.e., red, white, blue changes)

and if present will contact me immediately. We will see them back on a PRN basis or sooner should problems arise.

Figure 8 - Lesion noted by patient after a training run while wearing joggers

PinPointe - Initial Patient: [Patient.Name] Account No: [Patient.AcctNo] Date: [Date]

Chief Complaint: Discoloration of toenails. Condition has existed for [several months, over a year, many

years]. Condition [is, is not] painful. Commencement was [insidious, sudden, unsure as nail polish had

been on for so long]. Previous treatments include: [evaluation by a previous physician, over the counter

(OTC) topical agents, prescription topical agents, oral Lamisil in pulse dose, oral Lamisil in full dose, laser

treatments, over the counter (OTC) remedies, no treatment administered]. [Patient has a history of

complications with oral medicines.]

42


Medications: [Meds]




Review of Systems:

Eyes: [Eyes]

GI: [GI]

GU: [GU]

Gynecological: [Gynecological]






Physical Exam: [Vitals]

Vascular: Dorsalis pedis are graded at [1,2,3,5,4] and posterior tibial pulses are graded at [1,2,3,5,4] with

digital hair growth [present, absent] bilateral. CFT with the leg elevated was [less than 3 seconds, 3

seconds, more than 3 seconds] at the distal toes bilateral. There [is, is not] evidence of ischemic skin

changes. Temperature from the tibia to the toes is [warm, cool] at anterior tibia to [warm, cool] at the

distal digits bilateral.

Neurological: [Coordination WNL to right and left lower extremity] [Touch sensations are within normal

limits]

Dermatological: There is nail [thickening, elongation, splitting, discoloration, incurvation] of [Hot

Spots]. [There is normal texture, temperature, turgor and color of the skin.] [There is evidence of

peeling, scaling, and chronic dryness of the skin]

Musculoskeletal: Patient is [able to walk with ease, able to walk with a walker, in a wheelchair]. [Stable

foot posture without obvious structural deformities noted bilateral, malposition of foot structure at the

43

level of the forefoot, malposition of foot structure at the level of the mid-foot, malposition of foot structure at the level of the rear-foot, malposition of foot structure at the level of the ankle].

Impression: [Onycomycosis, hammertoes, tinea pedis, onychogryphosis, ingrown toenail]

Plan: We discussed treatment of onychomycosis. We discussed topical treatments, oral treatments, and

laser treatments using the PinPointe laser. After discussing the options, the patient decided to treat the

onychomycosis with PinPointe laser. The patient signed the consent form for the treatment, and was

advised not to paint toenails, during treatment period, for the next several months. Patient was advised

not to use nail salon, and not to pluck any material out from under the nail edge. A photograph was

taken of affected nails. [Manual and mechanical debridement of the mycotic nails was carried out.] Th e

laser procedure was performed on [all, both hallux nails,1R,2R,3R,4R,5R,1L,2L,3L,4L,5L] nails without

complications. The patient was lectured on the importance of practicing preventive measures, and

written instructions were given. I dispensed a complimentary antifungal spray to use in their shoes, and

an antifungal cream to use two times a day for two weeks, or until the skin is clear of infection. They are

then to continue using the cream twice weekly as a lifestyle. I discussed cleansing the showers with

household bleach and washing all socks and bed sheets in bleach. All questions answered. The patient will RTC in [1 month,2 months,3 months,4 months, PRN] for follow-up inspection and photographs.

Figure 9 – Pinpoint laser producer

44

Figure 10 – After application of Pinpoint

Figure 11 - PinPointe Laser machine

PinPointe - Follow-up

Patient: [Patient.Name] Account No: [Patient.AcctNo] Date: [Date] Chief Complaint: This patient returns for follow up after the first PinPointe laser treatment for

onychomycosis. The patient [is, is not, intermittently] practicing the preventive measures to avert

reinfection by using [antifungal cream on the skin, antifungal oil on the nails, spraying shoes with

Antifungal spray]. The patient [has, has not] noticed a significant improvement in the nail discoloration

and texture.

45

Physical Examination: There is [normal, abnormal] texture and color of the periungual skin. Plantar

skin is [clear of infection, improved in appearance of infection, not improved in appearance of infection].

Nails are [improving as expected, improving faster than expected, improving slower than expected, not

improving, worsening, resolved in appearance of infection]

Assessment: [onychomycosis, tinea pedis] [improving, unchanged, worsening, resolved]

Plan: We discussed the progress. Photographs were taken to document progress. Patient was lectured,

stressing the importance of [continuing to practice preventive measures using the same over the

counter (OTC) products, becoming more aggressive and moving to a prescription strength product].

[Retreatment with the PinPointe laser applied to the toenails in areas that appear to be infected with fungus.]

RTC [1 month, 2 months, 5 months, PRN] for follow-up inspection.

Ulceration - Initial Visit Patient: [Patient.Name] Account No: [Patient.AcctNo] Date: [Date]

Chief Complaint: This [Patient. Age] year old [Patient. Gender] presents today with an ulceration. The

ulcer has been present for several [days, weeks, months, years]. The condition is [worsening,

unchanged, improving]. Patient [has responded to, has not responded to, has not attempted] local wound care. Last seen by PCP, [Patient. Primary Physician] on [Patient. Date Last Seen].


Medications: [Meds]




Review of Systems:


ENMT: [ENMT]



GI: [GI]

46

GU: [GU]









their stated age and appears to be in good health. Their vitals are as follows: [Vitals]. The patient [does,

does not] show signs of systemic infection. Random blood sugar is: [under 70, between 70-100, in the

normal range, between 120-140, between 140-160, between 160-180, between 180-200, greater than

200] [??], oral temperature is [elevated, normal].

Dermatological: There is a lesion [Hot Spots]. The lesion measures [1,2,3,4,5,6,7,8,9,10] x

[1,2,3,4,5,6,7,8,9,10] [cm, mm]. The Base is [granular, fibrous, mixed]. Surrounding area is

[erythematous, edematous, normal] in appearance. There is [no, serosanginous, purulent] drainage. The

wound [does, does not] probe beyond the rim of the ulcer. Odor [is, is not] present. [Adequate, Inadequate] fat padding to the inferior aspect of each foot appreciated.

Neurological: Deep tendon reflexes including Achilles and Patellar are [normal, diminished, absent,

brisk] and symmetrical bilateral. Epicritic sensation including sharp-dull, light touch, proprioception, 2-


threshold (10.0 gram monofilament) are graded as [absent, diminished, normal, brisk, exaggerated] and

[with, without] focal motor or sensory deficit bilateral lower extremities. There are down going toes and

a negative clonus bilateral. Normal muscle mass appreciated to both the lower extremity and foot

bilateral. There [is, is not] pain on palpation of the wound.

Vascular: Dorsalis pedis [non-palpable (0/4), diminished (1/4), normal (2/4), strong (3/4), bounding

(4/4)] right and graded: [non-palpable (0/4), diminished (1/4), normal (2/4), strong (3/4), bounding

(4/4)] left. Posterior tibial pulses are graded: [non-palpable (0/4), diminished (1/4), normal (2/4), strong

(3/4), bounding (4/4)] right and graded: [non-palpable (0/4), diminished (1/4), normal (2/4), strong

(3/4), bounding (4/4)] left. Capillary filling time with the leg elevated is: [<3 sec., 4 sec., 5 sec., > 6 sec.]

at the level of the digital tufts bilateral. There [are, are not] ischemic skin changes evident bilateral lower

extremities.

Musculoskeletal: There [is, is not] deformity present.

Radiographs: Weight bearing radiographs of the symptomatic foot, with comparison views of the contralateral foot, reveal [no gross bony abnormalities, cortical disruption, cancellous changes].

47

Culture results [pending, reviewed]

Impression: Ulceration (Meggitt-Wagner Grade [0, 1, 2, 3, 4, 5]), [unchanged, improving, worsening]

Treatment: I have discussed the treatment options with the patient and have debrided their lesion

[partial thickness, full thickness, to subcutaneous tissue, to tendon and bone]. I dispensed some

offloading padding which they will reapply on a daily basis, recommended use of topical antibiosis for

twice a day application along with dry sterile dressings, and evaluated their shoes as well. I discussed

proper at home wound care techniques. The patient [will be able, will not be able, will need home

health] to perform these needed dressing changes. They will monitor their blood sugars and

temperatures and contact me immediately if further local or systemic signs of infection develop. We will

see them back in [1,2,3,4,5,6,7,8,9,10,11,12,13,14] days’ time or sooner should problems arise.

Dispensed [PolyMem, PolyMem with Ag, DuoDERM® dressing, sterile dressings, no dressings] x [1, 2, 3, 4, 5, 6].

RTC [3 days,1 week,2 weeks,4 weeks].

Ulceration - Follow-up Patient: [Patient.Name] Account No: [Patient.AcctNo] Date: [Date]

Chief Complaint: This [Patient. Age] year old [Patient. Gender] came in today for follow up of ulceration.

The condition is [worsening, unchanged, and improving]. Patient [has responded to, has not responded to, has not attempted] dressing changes.

No change in past medical history since last visit.

Review of Systems:



GI: [GI]





their stated age, and appears to be in good health. The patient [does, does not] show signs of systemic

infection. Random blood sugar is: [under 70, between 70-100, in the normal range, between 120-140,

48

between 140-160, between 160-180, between 180-200, greater than 200] [??], oral temperature is

[elevated, normal]. Neuro-vascular examination has not changed since previous visit.

Dermatological: There is a [improving, unchanged, worsening] lesion [Hot Spots]. The Base is [granular,

fibrous, mixed]. Surrounding area is [erythematous, edematous, normal in appearance]. There is [no,

serosanginous, purulent] drainage. The wound [does, does not] probe beyond the rim of the ulcer. No

varicosities, telangectasias, or other pigmented lesions. Venous stasis changes [present, not present]. [Adequate, inadequate] fat padding to the inferior aspect of each foot appreciated.

Radiographs: Weight bearing radiographs of the symptomatic foot with comparison views of the contralateral foot reveal [no gross bony involvement, cortical disruption, cancellous changes].

Culture results [pending, discussed].

Impression: Ulceration (Meggitt-Wagner Grade [0, 1, 2, 3, 4, 5]), [unchanged, improving, worsening]

Treatment: I have discussed the treatment options with the patient. Cultures [were, were not] taken. I

have debrided their lesion [partial thickness, full thickness] down to a healthy base. I have dressed and

dispensed some offloading padding which they will reapply on a daily basis, recommended use of topical

antibiosis for twice a day application along with dry sterile dressings, and evaluated their shoes as well. I

discussed proper at home wound care techniques. The patient [will be able, will not be able, will need

home health] to perform these needed dressing changes daily. They will monitor their blood sugars and

temperatures and contact me immediately if further local or systemic signs of infection develop. We will

see them back in [3 days, 1 week, 2 weeks, 4 weeks] time or sooner should problems arise. Dispensed

[0, 1, 2, 3, 4, 5, 6] [PolyMem foam dressings, PolyMem w/ Ag foam dressings, DuoDERM® dressing, sterile dressings, no dressings].

Ulceration of Toe - Initial Patient: [Patient.Name] Account No: [Patient.AcctNo] Date: [Date]

Chief Complaint: This [Patient. Age] year old [Patient. Gender] presents today with a dorsal ulceration

overlying a longstanding [first, second, third, fourth, fifth] toe deformity which has not responded to

soaks and over the counter (OTC) padding with shoe gear changes. Patient has not had a similar

condition previously, and denies any recent trauma or inciting events. Last seen by PCP, [Patient.

Primary Physician] on [Patient. Date Last Seen].


Medications: [Meds]




49

Review of Systems:


ENMT: [ENMT]



GI: [GI]

GU: [GU]









their stated age, and appears to be in good health. Their vitals are as follows: [Vitals]. The patient [does,

does not] show signs of systemic infection. Random blood sugar is: [under 70, between 70-100, in the

normal range, between 120-140, between 140-160, between 160-180, between 180-200, greater than 200] [??], oral temperature is [elevated, normal].

Dermatological: There is a deep seated hyperkeratotic lesion overlying the PIPJ of the [hallux, second,

third, fourth, fifth] toe. No varicosities, telangectasias, pigmented lesions or signs of venous stasis

changes bilateral lower extremities. Adequate fat padding to the inferior aspect of each foot appreciated.

Neurological: Deep tendon reflexes including Achilles and Patellar are [normal, diminished, absent,

brisk] and symmetrical bilateral. Epicritic sensation including sharp-dull, light touch, proprioception, 2-


threshold (10.0 gram monofilament) are graded as [absent, diminished, normal, brisk, exaggerated] and

[with, without] focal motor or sensory deficit bilateral lower extremities. There are down going toes and

a negative clonus bilateral. Normal muscle mass appreciated to both the lower extremity and foot bilateral. There [is, is not] pain on palpation of the toe in the region of the hyperkeratotic lesion.

Vascular: Dorsalis pedis and posterior tibial pulses are graded: [non-palpable (0/4), diminished (1/4),

normal (2/4), strong (3/4), bounding (4/4)] right and graded: [non-palpable (0/4), diminished (1/4),

50

normal (2/4), strong (3/4), bounding (4/4)] left. Capillary filling time with the leg elevated is: [<3 sec., 4

sec., 5 sec.,> 6 sec.] at the level of the digital tufts bilateral. There [are, are not] ischemic skin changes

evident bilateral lower extremities.

Musculoskeletal: There [is, is not] pain on palpation of the dorsal proximal phalanx of the [hallux,

second, third, fourth, fifth] toe where a hyperkeratotic lesion is evident which after debridement [does,

does not] reveal local signs of infection. There [is, is not] purulence, erythema, edema, ecchymosis and

the lesion [does, does not] probe deeply past the dermal layer. The toe is contracted in a semi -rigid

nature at the PIPJ with slight contracture evident to the MTPJ. There [are, are not] other significant foot or ankle deformities appreciated bilateral.

Radiographs: Weight bearing radiographs of the symptomatic foot with comparison views of the

contralateral foot reveal a contracted toe at the PIPJ level with some sagittal plane contracture at the

level of the MTPJ as well. The proximal phalanx head to the toe is enlarged with a moderate exostosis and [no, little, moderate, severe] evidence of periosteal elevation tumor, fracture, or cystic changes.

Impression: Symptomatic hammer digit syndrome [hallux, second, third, fourth, fifth] toe [with, without] ulceration (Meggitt-Wagner Grade [0, 1, 2, 3, 4, 5])

Treatment: I have discussed the treatment options with the patient and have debrided their lesion of

thickness, dispensed some toe strapping/silicone padding which they will reapply on a daily basis, and

recommended the use of topical antibiosis. I dispensed samples for twice a day application along with

dry sterile dressings, and stretched their shoes as well. Should these measures fail, I recommended an

incision and drainage with excision of the ulceration and an arthroplasty of the toe to correct the

condition. I discussed the risks, complications, and expected recovery course in detail. They will monitor

their blood sugars and temperatures and contact me immediately if further local or systemic signs of

infection develop. We will see them back in 3-5 days’ time or sooner should problems arise.

Figure 12 – Illustration of Ulcerated Foot

51

Verruca - Initial Patient: [Patient.Name] Account No: [Patient.AcctNo] Date: [Date]

Chief Complaint: This [Patient. Age] year old [Patient. Gender] presents today with complaint of a

painful area which may be a plantar [wart, warts].


Medications: [Meds]




Review of Systems:


ENMT: [ENMT]



GI: [GI]

GU: [GU]








Examination: The patient is appropriately dressed, articulate, awake, alert, and oriented x 3, appears their stated age, and appears to be in good health. Their vitals are as follows: [Vitals].

52

Vascular: Dorsalis pedis and posterior tibial pulses are readily palpable bilateral. Capillary filling time

with the leg elevated is <5 seconds at the level of the digital tufts bilateral. There are no ischemic skin

changes evident of bilateral lower extremities.

Musculoskeletal: Normal strength, range of motion and alignment for all joints from the ankle distal are evident bilateral.

Neurological: Unremarkable.

Dermatological: Raised, hyperkeratotic lesions with punctate capillary centers: [Hot Spots]. Otherwise,

there is no evidence of edema, erythema, ecchymosis, open lesions, interdigital maceration or signs of

bacterial or fungal infection bilateral lower extremities. No varicosities, telangiectasias, pigmented

lesions or signs of venous stasis changes of bilateral lower extremities. Adequate fat padding to the

inferior aspect of each foot appreciated.

Assessment: [Verruca plantaris, Abscess, Porokeratoma]

Plan: At this time [1, 2, 3, 4, 5, 6, 7, 8, 9, 10 or greater] plantar hyperkeratotic lesions were debrided with

a sterile scalpel blade. Next, application of canthecur acid to [less than 14 lesions, more than 14 lesions],

then, offloading and secondary mole skin dressing. We'll see patient back in two to three weeks for

follow-up evaluation.

Figure 13 – Verruca Plantar Wart

53

Verruca - Follow-up Patient: [Patient.Name] Account No: [Patient.AcctNo] Date: [Date]

Subjective: Patient returns to office for follow-up. Denies problems with acid therapy. Patient states the

lesions appear to be [improved, improving, worsening, unchanged, resolved].

Objective: Raised, hyperkeratotic lesions with punctate capillary centers which bleed upon

debridement: [Hot Spots]. Exam shows [expected mild inflammatory reaction, erythema, abscess,

completed treatment] as a result of the topical treatments.

Assessment: [Verruca plantaris, Abscess], [improving, resolved, worsening]

Plan: At this time [1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14 or greater] hyperkeratotic lesions were

debrided with a sterile scalpel blade. [Application of canthecur acid to lesions and then offloading and

secondary mole skin dressing, No further treatments needed]. RTC [11 days, 2 weeks, prn].

Musculoskeletal Achilles Tendonitis - Initial Patient: [Patient.Name] Account No: [Patient.AcctNo] Date: [Date]

Chief Complaint: Patient is a [Age] year old [Patient. Gender] who presents today with complaint of a

painful [right, left, bilateral] foot/ankle which has been present for several [days, weeks, months, years,

off and on for months, off and on for years]. The symptoms are worse upon [arising from sleep in the

morning, standing for long periods, walking, sitting then returning to activity, hard surfaces, duties at

work]. Patient has experienced [no recent trauma, recent straining during work, recent straining during

activity, trip and fall]. The pain is [improving, worsening, unchanged] since onset. Patient has been

treating this condition with [NSAIDS, shoe modifications, immobilization and non-weight-bearing, nothing just living with the discomfort, cessation of activity previous medical care].


Medications: [Meds]




Review of Systems:

54


ENMT: [ENMT]



GI: [GI]

GU: [GU]









Dermatological: There is [uniform swelling, ecchymosis, erythema, edema, heat, pain to palpation] of

the affected area. Remainder of the dermatological foot exam: [no varicositiestelangiectasias, pigmented lesions, signs of venous stasis changes, trophic changes].

Vascular: Dorsalis pedis and posterior tibial pulses are palpated at [0, 1, 2, 3, 4]/4 bilateral. Digital

capillary fill time is less than 3 seconds bilateral. There are no ischemic skin changes evident bilateral lower extremities.

Neurological: Achilles and Patellar reflexes are normal, brisk, and symmetrical bilateral. Epicritic

sensation including sharp-dull, light touch, proprioception, 2-point discrimination (< 12 mm at level of

hallux tuft), vibration (128 MHz tuning fork) and protective threshold (5.07 Semmes Weinstein

monofilament) are intact and without focal motor or sensory deficit bilateral lower extremities. There

are down going toes and a negative clonus bilateral. Normal muscle mass appreciated to both the lower

extremity and foot bilateral. The patient can heel and toe walk with ease as well as arise from a seated

position unassisted. Percussion of the tarsal tunnel and porta pedis [negative, positive] for Tinnel`s or Valieux sign [right, left, bilateral].

Musculoskeletal: Pain elicited on palpation of the Achilles tendon in the [watershed area, medial

insertion into the calcaneous, lateral insertion into the calcaneous, posterior insertion into the

calcaneous, superior posterior portion of the calcaneous, plantar portion of the calcaneous]. Ankle joint

ROM is [normal with a soft endpoint, normal with an abrupt endpoint, limited and under neutral,

55

worsening, improving] with the knee extended [bilateral, right, left]. The posterior heel has [no palpable

abnormality, fusiform swelling, palpable defect in the tendon substance, enlargement laterally,

enlargement medially, enlargement postero-superiorly]. Intact posterior tibial tendon, strength graded at 5/5. There are no other significant foot or ankle deformities bilaterally.

Radiographs: Weight bearing radiographs [1, 2, 3] views of the [right, left, bilateral] foot/ankle reveal

[no gross bony abnormalities, enthesophytes at the insertion into the calcaneous, haglunds deformity,

intra tendonous calcification(s),periosteal reaction, cortical disruption, fracture] of the calcaneous. Tendon contour [is, is not] abnormal.

Assessment: [Achilles tendonitis, Calcaneal Spur, Medial insertional tendonitis, Lateral insertional tendonitis, Achilles tendonosis, Haglunds deformity]

Plan: I discussed the pathology, it’s likely cause, and options for treatment. I discussed conservative

versus aggressive therapy. I will [mobilize, immobilize, treat] the tendon with [AirHeel™, Aircast® walker,

fiberglass cast, orthotic device, modified Jones compression cast, Soft paste cast, ankle stirrup, normal

athletic shoe]. [Patient was cautioned against high level activities, walking on uneven surfaces , and was

instructed to do stretching before arising suddenly or getting out of bed.] [At home physical therapy

discussed.] [Symptomatic use of an ice pack after activity for 10-15 minutes will help with the swelling

and discomfort.] [Rx options were discussed and patient cautioned regarding GI upset, ulcer and other

risks]. [Recommendations for shoe gear discussed.] Oral and written instructions given regarding

compliance. RTC [for additional EPAT treatments in 1, for additional injection in 1, 2, 3, 4, 5, 6, 12] week(s).

[EPAT treatment today 2000 pulses 10HZ at bar:]

Figure 14 – Illustration of Achilles Tendonitis

56

Figure 15 - AirHeel™

Figure 16 - Aircast®

57

Achilles Tendonitis - Follow-up Patient: [Patient.Name] Account No: [Patient.AcctNo] Date: [Date]

Chief Complaint: Patient presents today for follow-up of a painful [right, left] foot/ankle. Patient [has,

has not] been compliant with the home therapy program. Patient [is wearing the AirHeel as directed, is

not wearing the AirHeel™ as directed, is wearing the AirHeel™ but it has deflated, is doing the stretching

exercises as ordered, is wearing the orthotics as ordered, has stopped those activities that caused the condition to flare up]. Admits [not, 10%, 20%, 30%, 40%, 50%, 60%, 70%, 80%, 90%, 100%] improved.

Examination: The patient is appropriately dressed, articulate, awake, alert, and oriented x 3, appears their stated age, and appears to be in good health.

Dermatological: There is [less, no, more] [fusiform swelling, ecchymosis, erythema, edema, heat, pain to

palpation] of the affected area.

Musculoskeletal: Pain [elicited, not elicited] on palpation of the Achilles tendon in the [watershed area,

medial insertion into the calcaneous, lateral insertion into the calcaneous, posterior insertion into the

calcaneous, superior posterior portion of the calcaneous, plantar portion of the calcaneous, ankle]

[bilateral, right, left]. The posterior heel has [no palpable abnormality, fusiform swelling, palpable defect

in the tendon substance, enlargement laterally, enlargement medially, enlargement postero-superiorly].

Posterior tibial tendon, strength graded at [1/5, 2/5, 3/5, 4/5, 5/5]. [There are no other significant foot

or ankle deformities bilaterally.]

Radiographs: Weight bearing radiographs [1, 2, 3] views of the [right, left, bilateral] foot/ankle reveal

[no gross bony abnormalities, enthesophytes at the insertion into the calcaneous, haglunds deformity,

intra-tendonous calcification(s),periosteal reaction, cortical disruption, fracture] of the calcaneous.

Tendon contour [is, is not] abnormal.

Assessment: [Achilles tendonitis, Calcaneal Spur, Medial insertional tendonitis, Lateral insertional tendonitis, Achilles tendonosis, Haglunds deformity]

Plan: I discussed the pathology, it’s likely cause, and options for treatment. I discussed conservative

versus aggressive therapy. I will [mobilize, immobilize, treat] the tendon with [AirHeel™, Aircast® walker,

fiberglass cast, orthotic device, modified Jones compression cast, Soft paste cast, ankle stirrup, normal

athletic shoe]. [Patient was cautioned against high level activities, walking on uneven surfaces and was

instructed to do stretching before arising suddenly or getting out of bed.] [At home physical therapy

discussed.] [Symptomatic use of an ice pack after activity for 10-15 minutes will help with the swelling

and discomfort.] [Rx options were discussed and patient cautioned regarding GI upset, ulcer and other

risks]. [Recommendations for shoe gear discussed.] Oral and written instructions given regarding

compliance. RTC [for additional EPAT treatments in 1, for additional injection in 1, 2, 3, 4, 5, 6, 12]

week(s).

58

Achilles Wrap

A [right, left, bilateral] pre-fabricated [Ankle-Foot Orthosis, Ankle Gauntlet] was dispensed and fitted at

this visit. Due to the diagnosis of plantar fasciitis and related symptoms this is medically necessary for

treatment. The function of this device is to redistribute pressure, provide compression, and reduce

stress and strain of the fascia at the insertion into the calcaneus and along the Achilles tendon. The goals

and function of this device was explained in detail to the patient. Upon gait analysis, the device

appeared to be fitting well, and the patient states that the device is comfortable at this time. The

patient was shown how to properly apply, wear, and care for the device. The patient was able to apply

properly and ambulate without distress. At the time the device was dispensed, it was suitable for the

patient's condition and was not substandard. No guarantees were given, and precautions were

reviewed. Written instructions and warranty information was given along with the list of the twenty-one (21) Durable Medical Equipment Supplier Guidelines.

[L1902]

Figure 17 – Achilles Wrap

Ankle Exam

Examination of the left ankle reveals [no*, mild, moderate, severe] pain to palpation over the [anterior

talofibular ligament, calcaneofibular ligament, posterior talofibular ligament, peroneus brevis tendon,

peroneus longus tendon, sinus tarsi, medial malleolus, lateral mallelous]. The anterior drawer sign is

[negative*, positive]. The stress adduction test is [negative*, positive]. There [is, is no*] [edema,

59

warmth, ecchymosis] associated with the ankle joint. Range of motion in dorsiflexion is [under neutral,

to neutral but not past, 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, >10] degrees. Examination of the right ankle reveals

[no*, mild, moderate, severe] pain to palpation over the [anterior talofibular ligament, calcaneofibular

ligament, posterior talofibular ligament, peroneus brevis tendon, peroneus longus tendon, sinus tarsi,

medial malleolus, lateral mallelous]. The anterior drawer sign is [negative*, positive]. The stress

adduction test is [negative*, positive]. There [is, is no*] [edema, warmth, ecchymosis] associated with

the ankle joint. Range of motion in dorsiflexion is [under neutral , to neutral but not past, 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, >10] degrees.

Ankle instability/Sprain - Initial Patient: [Patient.Name] Account No: [Patient.AcctNo] Date: [Date]

Subjective: This is a [Patient.Age] year old patient presents today with a [new, recurring, additional]

painful [right, left, bilateral] ankle. Patient describes the area as [N]. The condition has existed for [D]

and began [O]. The ankle sprain is [C]. The affected area is made worse by [A]. Patient has been doing the following [T].



Medications: [Meds]




Review of Systems:


Eyes: [Eyes]




Gastrointestinal: [GI]

Genitourinary: [GU]


60







Objective: Patient is well developed and oriented x3 with [good*, poor] attention to grooming and body

habitus

Vascular: Dorsalis pedis pulses are [0, 1, 2*, 3, 4]/4 left, dorsalis pedis pulses are [0, 1, 2*, 3, 4]/4 right,

and posterior tibial pulses are [0, 1, 2*, 3, 4]/4 left, posterior tibial pulses are [0, 1, 2*, 3, 4]/4 right.

Capillary filling time with the leg elevated is [<5 right*, 5 right, >5 right, <5 left*, 5 left, >5 left] seconds

at the level of the digital tufts. There [is, are no*] ischemic skin changes evident in [left, right, bilateral*]

lower extremities. There [is, is not*] [edema*, pitting edema +??, non-pitting edema +??] noted lower extremity [left, right, bilateral*]. Digital hair [present*, not present]





[left, right, bilateral*]. [Negative*, Positive] Mulder`s sign to the interspaces of both feet. [Negative*, Positive] Tinel`s test to the medial aspect of the affected ankle.

Dermatological: There is [no, mild, intense] erythema and [no, scant, mild, moderate, severe] edema

[with, with no] [open sores, drainage, or signs of infection] of the affected area. There [is, is no]

[ecchymosis, warmth, laceration, fracture blisters] appreciated to the offending [anterior, posterior,

medial, lateral] ankle of [patient.hisher] [right, left, bilateral] ankle. [No*, There is] proximal cellulitis or deep abscess evident at this time.

Musculoskeletal: The foot type is [rectus, neutral, pronated, cavus] with [mild, no] gastro-soleus equinus

deformity. One notes [no*, mild] evidence of limb length discrepancy [?? mm right shorter than left, ??

mm left shorter than right]. Range of motion of the subtalar and midtarsal joints are pain free and

within normal limits on the [left foot, right foot, bilateral feet]. There [are, are no] [flexible, semi-rigid, rigid] digital contractures noted [1L, 1R, 2L, 2R, 3L, 3R, 4L, 4R, 5L, 5R].

Ankle Examination: Examination of the [left, right, bilateral] ankle reveals [no*, mild, moderate, severe]

pain to palpation over the [anterior talofibular ligament, calcaneofibular ligament, posterior talofibular

ligament, deltoid ligaments, medial ligaments, peroneal tendons, sinus tarsi, medial malleolus, lateral

mallelous]. The anterior drawer sign is [negative*, positive]. There [is, is no] [edema, warmth,

ecchymosis] associated with the symptomatic ankle. Muscle strength is [1, 2, 3, 4, 5]/5 for all four lower

extremity muscle groups [left, right, bilaterally]. There [is, is no] muscle guarding of the symptomatic [right, left, bilateral] ankle. ROM [is, is not] painful, [is, is not] limited and [crepitus is, is not] noted.

61

Radiographic Evaluation:

Views: 3 views of the [Right, Left, Bilateral] [Foot, Ankle*]. These views were [WB, NWB, AP, Lat, LO, MO, CA, SA, Mortise, HB, digital]

Soft Tissue Density: [WNL, Soft Tissue Lesions, Soft Tissue Swelling, Tendonous Calcifications, Tumor,

Vascular Calcifications]

Bone Quality/Density: [WNL, Osteoporosis, Osteopenia, Osteoarthritis, Joint space narrowing, Erosions,

Tophi, Cysts, Tumor, Osteophytes, Joint mice, Retrocalcaneal exostosis, Inferior plantar heel spur, Osteomyelitis, Open growth plates]

Fracture: [None, Displaced, Non-displaced, Healing, Oblique, Transverse, Avulsion, Comminuted, Stable,

Unstable, Open, Closed, Stress, Acute, Chronic]

Impression: [??]

Assessment:

[729.5][782.3][728.4]

Plan:

[99203]

[73610]

[20605][j3301][j1100]

Discussed with patient shoe gear changes, braces, functional orthotic devices, strappings, cast

immobilization, cortisone injections, physical therapy, anti -inflammatories, and possible need for surgical correction.

We have three clinical objectives: to reduce inflammatory processes, re-establish biomechanical

function of the ankle, and re-establish appropriate strength, range of motion and tolerance to eccentric

load and forces typical of standing, walking and running. Our goal is for the condition and symptoms to not advance to the stage of becoming chronic or recalcitrant.

Patient was warned of potential for ligament rupture and possible need for MRI may be warranted.

Discussed possible need for physical therapy referral.

Patient to follow-up: [1 week, 2 weeks, 3 weeks, 4 weeks, 1 month, 2 months, 3 months, PRN]

[Unna boot applied, right ankle, left ankle, bilateral ankle]

[Recommend Velocity brace for the patient for biomechanical control and reduction of pain and discomfort.]

62

[A Pneumatic Ankle-Foot Orthosis pre-fabricated Aircast® foam walker was dispensed and applied at

this visit. Due to the diagnosis and related symptoms this is medically necessary for the treatment. The

function of this device is to restrict and limit motion provide stabilization immobilization and

compression to the area affected. The goals and function of this device was explained in detail to the

patient. Upon gait analysis the device appeared to be fitting well and the patient states that the device is

comfortable at this time. The patient was shown and told in detail have to properly wear and care for

the device. They were able to apply the device properly themselves and able to ambulate without

distress of device. At that time the device was dispensed it was suitable for their condition and not

substandard. No guarantees were given and precautions reviewed. Written instructions and warrantee information was given and the list of the twenty-five Durable Medical Equipment Supplier Guidelines.]

Ankle Sprain Patient: [Patient.Name] Account No: [Patient.AcctNo] Date: [Date]

Subjective: Patient presents today for c/o injury to the [left, right ankle] about [1, 2, 3, 4, 5, 6, 7, 8, 9, 10,

14, 21, 28] days ago. States [Patient.heshe] [did, did not] hear a pop. Patient [has, has not] been able to walk. States the pain is [improved, unchanged, worsened] since the injury.



Musculoskeletal: There [is, is no, still some, still moderate, still severe] pain on palpation and edema of

the [ATFL, CF ligament, ankle joint medially, ankle joint laterally]. There are no other significant foot or ankle deformities appreciated bilaterally. ROM guarded at this point. Achilles tendon intact.

Dermatological: There [is, is not] erythema overlying the [right, left] ankle. Otherwise, there is no

evidence of edema, erythema, ecchymosis, open lesions, interdigital maceration or signs of bacte rial or

fungal infection bilateral lower extremities. No varicosities, telangiectasias, pigmented lesions or signs

of venous stasis changes to bilateral lower extremities. Adequate fat padding to the inferior aspect of each foot appreciated.

Assessment: Sprain ankle [right, left]

Plan: I have discussed the treatment options once again with the patient and have recommended

continued non-weight bearing course of treatment for an additional [1, 2, 4, 6, 8] weeks. I discussed

injection therapy for pain relief. I explained this is simply a relief of symptoms and not a cure.

[Patient.HeShe] seems to understand. Patient [desires, does not desire] to have an injection. The

patient was given the opportunity to ask questions which were answered satisfactorily to the best of my

ability. Aircast® [dispensed, not dispensed]. The patient voiced no concerns and will consider all these options and schedule for follow-up in 2-3 weeks.

63

Aspiration

The area over the lesion was blocked with 2% lidocaine with Epinephrine 1:100,000. After testing for

anesthesia an 18 gauge needle was used to aspirate [but no fluid was expressed, less than 1ml, less than

2ml, less than 5ml, less than10ml, more than 10ml]. The material was [gelatinous and clear, gelatinous

and cloudy, pus, granular, mixed blood, blood]. Area all material was expressed, the area was cleansed and covered with a dry sterile dressing.

Bunion Exam Radiographic [2, 3] view exam of the 1st MPJ [right, left] reveals the joint space to be [intact and normal,

narrowed medially, narrowed laterally, narrowed centrally, completely degenerated]. The ROM of the

1st MPJ is [full and without crepitation, limited, non-painful, painful, with crepitation, stiff, guarded].

The 1st ray is [hypermobile, not hypermobile]. The tibial sesamoid position is [1, 2, 3, 4, 5, 6, 7]. The IM

1-2 angle is [under 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, over

30]. The HA angle is [under 16, 17, 18, 19, 20, 21, 22, 23, 24, over 25]. The PASA is [under 7, 8, 9, 10, 11,

12, 13, 14, 15, 16, 17, over 18]. The DASA angle is [under 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, over 18].

On lateral views the 1st ray is rectus, [is in elevatus, shows dorsal heterotopic bone formation at the

metatarsal head, spurring at the metatarsal head]. [Subchondral eburnation is present.] The metatarsal

parabolas reveals [normal metatarsal parabola*, elongated 1st metatarsal length, short 1st metatarsal length, long 2nd metatarsal length]. The hallux [is, is not] crowding the 2nd digit.

Figure 18 – Bunion

64

Bunion - Initial Patient: [Patient.Name] Account No: [Patient.AcctNo] Date: [Date]

Chief Complaint: This [Patient.Age] year-old [Patient.Gender] presents to the office with a chief

complaint of pain in [right, left, bilateral] great toe joint which has been present for several [weeks,

months, years]. Patient complains of [throbbing, aching, burning, pain in shoes, pain with ambulation,

no pain, pain under the foot, deforming toes, irritation between toes]. Symptoms present for [several

weeks, several months, years, worsening]. Previous treatment includes [rest, ice, anti-inflammatories,

strapping, OTC orthotics, injections, padding, shoe modifications, nothing just living with the pain,

lifestyle modifications, cessation of activity, change in job]. Podiatric history [evaluation by previous

doctor, unremarkable, present, indicates previous injury to this area, indicates no previous injury to this area, indicates previous surgery to the area, physical therapy, medicinal therapy].


Medications: [Meds]



Past Family History: [PFH]


Review of Systems:


ENMT: [ENMT]



GI: [GI]

GU: [GU]






65





Neurovascular: No breaks in the skin or sign of infection or rashes were noted bilaterally. Sensation

intact proximal to distal bilaterally. Parasthesias [are, are not] elicited to percussion of the medial eminence [right, left, right and left].

Musculoskeletal: There is a [mild, moderate, severe] hallux abducto valgus and bunion deformity seen

on the [right, left, bilateral] foot. There [is, is no] crepitus upon range of motion [right, left, bilateral].

The joint [is, is not] track bound [right, left, bilateral]. Localized redness and swelling is seen on the

dorso-medial aspect of the first metatarsophalangeal joint of the [right, left, bilateral] foot consistent

with bursitis and capsulitis. Gait analysis and a biomechanical examination show [an excessively

pronated, hypermobile, rectus] foot type. First ray is [hypermobile, not hypermobile]. The 2nd digit is

[contacted at the PIPJ, contracted at the DIPJ, contracted at the MPJ, overlapping the hallux,

underlapping the hallux, not contracted].

Dermatology: Patient presents with [no skin changes, callousing of the medial IPJ, dorsal callous, sub 1st MPJ callous, sub 2nd MPJ callous, lessor metatarsal callous].

Radiology: An AP and Lateral weight bearing x-ray of the [right, left, bilateral] foot was taken, which

does reveal a hallux abducto valgus deformity with increased [inter-metatarsal, hallux abductus, tibial

sesamoid position, PASA, DASA] angle(s).

Assessment: HAV deformity of [right, left, bilateral] foot.

Plan: The conditions, etiologies, options for care, treatment plan, and prognosis were discussed with

the patient. Both conservative and surgical options for care were reviewed. The abnormal biomechanics

of their feet were reviewed as it relates to their conditions and symptoms. Proper shoe gear was

reviewed as well as padding of the bunion. I suggested [continue with current shoe gear, new more

accommodating shoes, to wear slippers for accommodation]. All questions were answered in detail. The

plan at this point is to [monitor for progression, correct the deformity, treat the symptoms

conservatively, proceed with orthotic therapy]. Patient to RTC in [2 weeks, 3 weeks, 4 weeks, 6 weeks, 12 weeks, prn].

Bunion - Follow-up Patient: [Patient.Name] Account No: [Patient.AcctNo] Date: [Date]

Subjective: Patient presents today for follow-up with continued complaint of pain and deformity to the

[right, left, bilateral] great toe with pain associated with closed-toed shoe gear. Patient did well with the

66

padding but has noticed a significant recurrence of the pain even with changes in shoe gear and padding.



Musculoskeletal: There is pain on palpation of the proximal phalanx of the [right, left, bilateral] great toe

at the level of the first [right, left] MTPJ. The toe has remained in a contracted position and is semi-rigid

in nature as previously described. There are no other significant foot or ankle deformities appreciated bilaterally.

Dermatological: There is fixed erythema overlying the first [right, left] MTPJ consistent with shoe gear

related irritation. Otherwise, there is no evidence of edema, erythema, ecchymosis, open lesions,

interdigital maceration or signs of bacterial or fungal infection bilateral lower extremities. No

varicosities, telangiectasias, pigmented lesions or signs of venous stasis changes to bilateral lower

extremities. Adequate fat padding to the inferior aspect of each foot appreciated.

Assessment: Symptomatic HAV and HAI deformity [right, left] foot.


continued use of the silicone padding/strapping dispensed at previous visit, recommended use of

Vaseline or similar product to decrease friction, and have again stretched shoes as well. Since patient

has not realized significant long-term benefit from these conservative measures I recommended surgical

intervention as discussed in previous visit. Patient has been advised of the approximate disability






biomaterials, over-correction, under-correction with recurrence of the deformities, continued pain, and


ask questions which were answered satisfactorily to the best of my ability. The patient voiced no

concerns and will consider all these options and schedule accordingly.

Calcaneal Apophysitis - Initial Patient: [Patient.Name] Account No: [Patient.AcctNo] Date: [Date]

Subjective: [Patient.age] year-old who presents to the office with [patient.hisher] [parents, mother,

father] with a chief complaint of pain in the [right, left, bilateral] heel. They state that this has been

present for approximately [D] and becoming progressively more severe. The pain is increased with

ambulation and weight bearing and does feel better with rest. They indicate the pain is most severe after playing sports and running. They relate [no*, positive] history of trauma.

67



Medications: [Meds]




Review of Systems:


Eyes: [Eyes]





Genitourinary: [GU]








Objective: Patient is well developed, alert and oriented x 3 with [good*, poor] attention to grooming and body habitus.

Vascular: Dorsalis pedis pulses are [0, 1, 2*, 3, 4]/4 left, dorsalis pedis pulses are [0, 1, 2*, 3, 4]/4 right,

and posterior tibial pulses are [0, 1, 2*, 3, 4]/4 left, posterior tibial pulses are [0, 1, 2*, 3, 4]/4 right.

Capillary filling time with the leg elevated is [<5 right*, 5 right, >5 right, <5 left*, 5 left, >5 left] seconds

at the level of the digital tufts. There [is, are no] ischemic skin changes evident in [left, right, bilateral*]

lower extremities. There [is, is not*] [edema*, pitting edema +??, non-pitting edema +??] noted lower extremity [left, right, bilateral*].



68



[left, right, bilateral*]. [Negative*, Positive] Mulder`s sign to the interspaces of both feet.

Dermatological: Color, texture, and turgor are within normal limits, bilateral lower extremity, and there are no open lesions. Pedal and digital hair are present

Musculoskeletal: One notes a [rectus*, planus, cavus] foot type with [mild, no] gastroc-soleus equinus

deformity. One notes [no*, mild] evidence of limb length discrepancy [?? mm right shorter than left, ??

mm left shorter than right]. Range of motion of the ankle, subtalar and midtarsal joints [are, are not]

pain free and within normal limits [right, left, bilateral] and is tender on dorsiflexion both forced and

passive range of motion [right, left, bilaterally]. Reveals pain with palpation to the posterior plantar

aspect of the [left, right, bilateral] heel at both the insertion of the Achilles tendon and the posterior

calcaneus. There [is*, is not] pain on medial to lateral compression of the calcaneus. There are [no*,

some] [flexible, semi-rigid, rigid] digital contractures noted. Muscle strength is [1, 2, 3, 4, 5]/5 for all four

lower extremity muscle groups on the non-effected foot guarded on the effected foot.

Radiological Examination: X-rays 3 views weight bearing [Lateral, Reverse lateral, calcaneal axial, AP,

MO, LO] taken and reviewed of the [left, right, bilateral] foot. X-rays show [good*, diminished] bony

density, clarity of all joint spaces. One notes that there is no evidence of any fractures, subluxations or dislocations noted. The calcaneal growth plates are [open*, closed]

Assessment:

[729.5][732.5][726.90][727.3]

Plan:

[99203]

[73620]

Lengthy discussion with patient about medical condition, prognosis and treatment plan. The abnormal

biomechanics of their feet were discussed as it relates to their conditions and symptoms. They were

advised that the condition may take years to completely resolve and is related to age and development,

and also that the condition may relapse and remit over time. I advised custom-made functional orthotic

devices to control the biomechanical abnormalities and reduce the stress and strain at the insertion of

the plantar fascia and Achilles tendon into the calcaneus. Patient was instructed to be [non, partial,

complete] weightbearing. Home PT exercises were given, both oral and written. I advised a proper

warm-up and stretching prior to playing sports and doing other athletic activities. Heel pads were

dispensed and instructions given. I recommended applying ice to the area especially after playing sports

and activity. Proper shoe gear was reviewed. Discussed the use of OTC Tylenol and Ibuprofen and

recommended occasional use for pain reduction. I advised caution due to potential side effects and recommended immediate discontinuation if side effects arise.

Patient to return to clinic in [1, 2, 3] [week, month]

69

Figure 19 – Illustration describing Calcaneal Apophysitis

Capsulitis - Initial Patient: [Patient.Name] Account No: [Patient.AcctNo] Date: [Date]


complaint of a painful [right, left] [toe, foot, ankle] which has been present for [days, weeks, months,

years]. Patient [has, has not] experienced recent trauma. Patient rates pain as [1, 2, 3, 4, 5, 6, 7, 8, 9,

10]/10, (10 being the worst). Patient has been treating this condition with [NSAIDS, shoe modifications, immobilization and non-weight-bearing, bracing].


Medications: [Meds]



70


Review of Systems:


ENMT: [ENMT]



GI: [GI]

GU: [GU]









Dermatological: There is [ecchymosis, erythema, edema, heat, pain to palpation] of the affected

area. No varicosities, telangiectasias, pigmented lesions or signs of venous stasis changes bilateral lower

extremities. [Adequate, In-adequate] fat padding to the inferior aspect of the feet. Skin is normal color and turgor otherwise.

Vascular: Dorsalis pedis and posterior tibial pulses are palpated at [1, 2, 3, 4]/4 bilateral. Digital capillary fill time is <5 seconds bilateral. There are no ischemic skin changes evident bilateral lower extremities.





are downgoing toes and a negative clonus bilateral. Normal muscle mass appreciated to both the lower


position unassisted. Percussion of the tarsal tunnel and porta pedis [negative, positive] for Tinnel`s or

Valieux sign [right, left, bilateral].

71

Musculoskeletal: Pain elicited on palpation of the [1st, 2nd, 3rd, 4th, 5th] metatarsophalangeal joint. There [are, are not] significant foot and/or ankle deformities [right, left, bilaterally].

Radiographs: Weightbearing radiographs 3 views of the symptomatic foot reveal [subluxation,

misalignment, malalignment] of the [1st, 2nd, 3rd, 4th, 5th] [PIPJ, MPJ, M-C joint, N-C joint, STJ, T-N joint, ankle joint medially, ankle joint laterally].

Assessment: Capsulitis [right, left] [PIPJ, MPJ, M-C joint, N-C joint, STJ, T-N joint, ankle joint medially, ankle joint laterally].

Treatment: I discussed the pathology, it’s likely cause, and options for treatment. I discussed

conservative versus aggressive therapy. Will immobilize the part with [Aircast®walker, fiberglass cast,

modified Jones cast, Soft paste cast, ankle stirrup, orthotic] completely refraining from unassisted

walking. Recommend wear the device every day as the structure of the foot allows. Discussed injection

therapy for pain relief. Pt [desires, does not desire] this. Oral and written instructions given regarding compliance. RTC in [1, 2, 3, 4, 6, 12] weeks.

Injection: 1 cc dexamethasone phosphate injected into symptomatic joint. Patient tolerated this well.

Figure 20 – Capsulitis

72

Capsulitis - Follow-up Patient: [Patient.Name] Account No: [Patient.AcctNo] Date: [Date]

HPI: [Patient.FirstName] is a [Patient.Age] year old [Patient.Gender] returns for follow up. The patient

admits [10%, 20%, 30%, 40%, 50%, 60%, 70%, 80%, 90%, 100%, no] improvement. Patient [Is not using

any assistive devices, has been wearing the Budin splint, has not been wearing the Budin splint against orders, has been wearing the Darco™ toe alignment splint].

PMHx: [PMH]

Medications: [Meds]


Examination: Alert & Oriented x 3. Presents in no acute distress.

Musculoskeletal: There is [minimal, still some, moderate, severe, no] tenderness with palpation of the

plantar 2nd MPJ [right, left] foot. The plantar aspect of the 2nd MPJ is [not, slightly, quite]

thickened/swollen. The 2nd toe is [not, mildly, moderately, severely, flexibly, rigidly] dorsally contracted at the MPJ.

Dermatological: There is [sub 2nd callus, no sub 2nd callus, focal lesion, diffuse tyloma] present.

Assessment: Capsulitis [with hammertoe, with Predislocation Syndrome] 2nd metatarsal phalangeal joint [right, left] foot.

Plan: I discussed the nature of the problem and treatment options with the patient. [I recommend use

of supportive thick soled shoes for all standing and discussed orthotic therapy, OTC inserts were

modified and dispensed., Patient instructed on how to tape the toe down (tape dispensed)., Hammertoe

regulator pad was dispensed to hold the toe down., Continue using the Budin splint., Ice the forefoot at

the end of the day., Avoid strenuous activities such as prolonged standing or running., I discussed

continued treatment with steroid injections and the possible complications associated., I discussed possible surgical correction of the contributing deformity.]

RTC [1 week, 2 weeks, 3 weeks, 4 weeks, 5 weeks, 6 weeks, 7 weeks, 8 weeks, 9 weeks, 10 weeks, 11

weeks, 12 weeks, prn] .

Charcot - AFO Patient: [Patient.Name] Account No: [Patient.AcctNo] Date: [Date]

Chief Complaint: Patient presents today complaining of [pain, redness, swelling] to [patient.hisher] [left,

right] foot. This problem has been going on since [today, yesterday, ?? days, ?? weeks]. [Patient.HeShe]

[has, has not] been seen or evaluated by any other physicians for this condition. The patient has been

73

diabetic for [<5, 5-10, 10-15, 15-20, >20] years. [Patient.HeShe] [admits, denies] diabetic peripheral

neuropathy. [Patient.HeShe] has not been able to wear [patient.hisher] normal shoes due to the

swelling. [Patient.HeShe] [has, has not] noticed a significant change in the shape of the foot. The patient

rates their pain on a scale of 1-10, with 10 being the worst, the patient states [patient.hisher] pain is a(n): [0, 1, 2, 3, 4, 5, 6, 7, 8, 9, 10]/10

Patient states that their latest blood sugar is: [unknown, under 70,between 70-100, in the normal range,

between 120-140, between 140-160, between 160-180, between 180-200, greater than 200, greater than 300, greater than 400] and they state that their oral temperature is [elevated, normal, unknown].


Medications: [Meds]




Review of Systems:


Eyes: [Eyes]

Head/Ears/Nose/Throat: [Head/Ears/Nose/Throat]

Cardiovascular: [Cardiovascular]



Gastrointestinal: [Gastrointestinal]


Musculoskeletal: [Musculoskeletal]



Genitourinary: [Genitourinary]


74

Physical Exam: The patient appears well nourished and well groomed, NAD. [Vitals] Most recent blood sugar/A1c

Vascular: Dorsalis pedis are graded at [0/4, 1/4, 2/4, 3/4, 4/4, dopplerable on the right, dopplerable on

the left, non-dopplerable on the right, non-dopplerable on the left]. Posterior tibial pulses are graded at

[0/4, 1/4, 2/4, 3/4, 4/4, dopplerable on the right, dopplerable on the left, non-dopplerable on the right,

non-dopplerable on the left]. Digital hair growth on the toes is [present, sparse, absent]. CFT with the

leg elevated was [less than 3 seconds, 3 seconds, more than 3 seconds] at the distal toes bilateral. There

[is, is not] evidence of ischemic skin changes. Temperature from the tibia to the toes is [warm, cool,

cold] at anterior tibia to [warm, cool, cold] at the distal digits bilateral. Lower extremity edema is [not

present, 1+, 2+, 3+, 4+, late stage with a brawny appearance, champagne bottle appearance].

Neurological: Balance and coordination [WNL, guarded, antalgic, difficulty sitting or standing]. Epicritic

sensation, as measured with a 5.07 Semmes Weinstein Monofilament is [intact, diminished, absent] in

[1, 2, 3, 4, 5, 6, 7, 8, 9, 10] out of 10 areas of the toes, plantar foot forefoot, plantar arch, heel, and

dorsum. Vibratory sensation as measured with a 128Hz tuning fork is [intact, diminished compared to

the hand by 2 seconds, diminished compared to the hand by 4 seconds, diminished compared to the

hand by 6 seconds, diminished compared to the hand by 8 seconds, diminished compared to the hand by 10 seconds or more, absent]. [Clonus is present.]

Dermatological: Erythema is [not present, present at the hallux, 2nd digit, 3rd digit, 4th digit, 5th digit,

plantar aspect, dorsal aspect] of the [bilateral, right, left] foot. At risk areas are [not present, present

due to digital deformities, present due to bunion deformities, present due to calloused areas susceptible to ulceration]. Pre-ulcerative areas [are, are not] present. Open ulcerations are [absent, present].

Musculoskeletal: Equinus deformity is noted to affected limb. Rocker bottom foot structure [OPTION=is

noted, is not noted]. Osseous hypertrophy noted to the [plantar aspect of midfoot, ankle joint,

MPJ]. [Increased, Decreased, Flailed, Rigid, Apparent normal] range of motion noted to the [MPJ joints, tarsometatarsal junction, midfoot, ankle].

X-rays findings: [2 views left foot, 2 views right foot, 3 views right foot, 3 views left foot, 2 views right

ankle, 2 views left ankle, 3 views right ankle, 3 views left ankle] reveal: The orthopedic structure of the

foot demonstrates [soft tissue swelling, increased sclerosis, bony collapse at the midfoot creating a

"rocker bottom" type deformity, bony fragmentation, extensive fracturing throughout the midfoot,

extensive fracturing throughout the ankle, spurring of affected joint, decreased calcaneal inclination angle, dislocation of cuboid].

Assessment:

Charcot Joint

Edema, Localized

Pain in Toe/Limb

75

Plan:

The nature of the problem was discussed with the patient and we discussed the severity of

[patient.hisher] medical condition. The patient understands that this a limb-threatening condition and

will require strict adherence of physician instruction as well as proper control of [patient.hisher] blood

sugar. The patient was instructed that excessive weight bearing on the affected limb can cause further breakdown of the foot leading to further ulceration, infection, loss of limb and loss of life.

[I prescribed, I will defer prescribing, Dispensed, Applied] a [CROW boot, pneumatic Aircast®, below

knee cast, total contact cast] for the patient at this time. The foot will need [Aircast® immobilization,

cast immobilization, custom-molded immobilization and compression] to reduce or prevent further

damage and deformity from developing and to encourage coalescence and consolidation of the af fected

bones and joints. It was reiterated to the patient that this device is to aid the patient with ambulation

but that limitation of weight bearing on the foot is essential for resolution of the acute phase of Charcot arthropathy.

[Due to the clinical and radiographic evidence of Charcot arthropathy/infection and possible

osteomyelitis it was recommended to the patient that hospitalization is required for IV antibiotic

therapy and surgical debridement. The Hospitalist on-call has been notified for medical co-management and an infectious disease consultation has been ordered.]

I have recommend that the patient remain [full-weight bearing, non-weight bearing, minimal weight bearing.]

[Patient.HeShe] will return to the office in [1, 2, 3, 5, 6, 7, 8, 9, 10] [day(s), week(s), month(s)] for follow-

up.

Figure 21 – Illustration of Normal Foot

76

Figure 22 - Illustration of Charcot Foot

Figure 23 - Patient presenting with Charcot Foot

Contusion Foot/Toe - Initial Visit Patient: [Patient.Name] Account No: [Patient.AcctNo] Date: [Date]

Chief Complaint: This [Patient.Age] year old [Patient.Gender] presents today with a complaint of a pain

[right, left] [hallux*, 2nd digit, 3rd digit, 4th digit, 5th digit, foot] which has [redness, drainage, swelling]

and has not responded to self-treatment. Patient relates a history of injury on [??]. The injury occurred at [home, work]. The pain level is [??]/10, and [is, is not] improving.

77



Medications: [Meds]




Review of Systems:


Eyes: [Eyes]




GI: [GI]

GU: [GU]








Examination: The patient is appropriately dressed, articulate, awake, alert, and oriented x 3, appears stated age and looks to be in good health.

Dermatological: There is ecchymosis of the [right, left] [hallux*, 2nd digit, 3rd digit, 4th digit, 5th digit,

foot]. No proximal cellulitis or deep abscess noted. No open lesions or cardinal signs of bacterial or

fungal infection to the remainder of either foot.

Neurological: Pain is appreciated is appreciated in and around the site of injury. Deep tendon reflexes

including Achilles and Patellar are normal, brisk, and symmetrical bilateral. Epicritic sensation including

78

sharp-dull, light touch, proprioception, 2-point discrimination (< 12 mm at level of hallux tuft), vibration

(128 MHz tuning fork) and protective threshold (10.0 gram monofilament) are intact and without focal

motor or sensory deficit bilateral lower extremities. There are downgoing toes and a ne gative clonus

bilateral. Normal muscle mass appreciated to both the lower extremity and foot bilateral. The patient [can, cannot] heel and toe walk with ease.

Vascular: Dorsalis pedis and posterior tibial pulses are [0, 1, 2*,]/2 bilateral. Capillary filling time with the

leg elevated is [<5*, 5,>5] seconds at the level of the digital tufts bilaterally. There are no ischemic skin changes identified B/L.


anterior drawer), hindfoot, midfoot and forefoot bilateral lower extremities. Patients gait [is*, is not]

antalgic. Muscle strength for all prime movers of the lower leg, ankle, and foot are graded at 5/5

bilateral lower extremities. Appropriate muscle tone and symmetry bilateral lower extremities. Full, fluid range of motion for all joints from the ankle joint distal without crepitation or instability.

X-rays: [Radiographic examination reveals no abnormalities. There is no evidence of spurring, fracture, foreign body, or joint space narrowing.] Impression: Contusion [right, left] [hallux*, 2nd digit, 3rd digit, 4th digit, 5th digit, foot]. Plan: I have discussed my findings with the patient. I recommend [ice, rest, elevation, compression with ace wrap, and surgical shoe]. Patient was given an Rx for [Daypro 1200mg QD, Naprosyn 500mg BID, Vicodin, Tylenol #3]. We will see the patient in follow-up in 1-2 weeks or sooner should any problems arise.

Figure 24 - Contusion on Left Ankle

EPAT Patient: [Patient.Name] Account No: [Patient.AcctNo] Date: [Date]

79

Patient admits improvement of [0, 10, 15, 20, 25, 30, 40, 45, 50, 75, 100] % so far with treatment.

EPAT [1000, 1500, 2000] pulses at [1.5, 1.6, 1.7, 1.8, 1.9, 2.0, 2.1, 2.2, 2.3, 2.4, 2.5, 2.6, 2.7, 2.8, 2.9, 3.0]

bar at [10, 11] Hz to the [Left, Right, bilateral] foot. Patient [tolerated treatment well, did not tolerate

treatment very well, was unable to finish treatment due to discomfort].

Patient to RTC in [1, 2, 3, 4, 5, 6, 7, 14, 28] days.

ETOH Injection Patient: [Patient.Name] Account No: [Patient.AcctNo] Date: [Date]

Subjective: Patient presents today for follow-up evaluation of symptomatic neuroma, [right, left] [1st,

2nd, 3rd, 4th] interspace. Admits [improvement, no changes since previous visit, is starting to improve,

able to move toes freely once again, able to wear shoes without pain] with 4% dehydrated alcohol

injection [#1, #2, #3, #4, #5, #6, #7, #8, #9]. Patient denies any complications arising out of the current therapy. Patient [desires, does not desire] to continue this line of treatment.

PMH, PSH, Meds: Reviewed in detail and unchanged since last examination.

Objective: Unchanged vascular and dermatological status bilateral lower extremity.

Musculoskeletal: There continues to be [pain, no pain, less pain] on palpation of the lesser metatarsal

heads or MTPJ plantar plates with stable digital exams. There are no other significant foot or ankle

deformities appreciated, stable foot posture, and adequate muscle strength to manual examination bilaterally.

Neurological: There is [significant, moderate, mild, minor, no] pain of the [ right, left] [1st, 2nd, 3rd, 4th]

inter-digital space. [+,-] Mulder`s sign with medial-lateral compression of the interdigital space and deep palpation of the interspace.

Assessment: Symptomatic [Morton's, interdigital] neuroma, [right, left] [1st, 2nd, 3rd, 4th] interspace, [improving, unimproved, worsening].

Plan: I have discussed the treatment options with the patient and recommended continued use of the

alcohol sclerosing agent. Hemostasis was achieved with compression, the skin was cleansed, and a dry

sterile dressing applied. We will see them back in 11-14 days’ time to re-evaluate the situation or

sooner should problems arise. If these conservative measures fail and the symptoms warrant I would

recommend a custom made orthoses or surgical excision. I discussed the risks, complications, and

expected recovery course in detail. Injection [#1, #2, #3, #4, #5, #6, #7, #8, #9] with 4% ETOH in 0.5% Marcaine™ plain w/ epinephrine. Patient tolerated this well.

80

ETOH Injection Patient: [Patient.Name] Account No: [Patient.AcctNo] Date: [Date]


2nd, 3rd, 4th] interspace. Admits [improvement, no changes since previous visit, is starting to improve,

able to move toes freely once again, able to wear shoes without pain] with 4% dehydrated alcohol

injection [#1,#2,#3,#4,#5,#6,#7,#8,#9]. Patient denies any complications arising out of the current therapy. Patient [desires, does not desire] to continue this line of treatment.

PMH, PSH, Medications: Reviewed in detail and unchanged since last examination.


Musculoskeletal: There continues to be [pain, no pain, less pain] on palpation of the lesser metatarsal

heads or MTPJ plantar plates with stable digital exams. There are no other significant foot or ankle

deformities appreciated, stable foot posture, and adequate muscle strength to manual examination bilaterally.

Neurological: There is [significant, moderate, mild, minor, no] pain of the [right, left] [1st, 2nd, 3rd, 4th]

inter-digital space. [+, -] Mulder`s sign with medial-lateral compression of the interdigital space and

deep palpation of the interspace.

Assessment: Symptomatic [Morton's, interdigital] neuroma, [right, left] [1st, 2nd, 3rd, 4th] interspace, [improving, unimproved, worsening].


alcohol sclerosing agent. Hemostasis was achieved with compression, the skin was cleansed, and a dry

sterile dressing applied. We will see them back in 11-14 days’ time to re-evaluate the situation or

sooner should problems arise. If these conservative measures fail and the symptoms warrant I would

recommend a custom made orthoses or surgical excision. I discussed the risks, complications, and

expected recovery course in detail. Injection [#1,#2,#3,#4,#5,#6,#7,#8,#9] with 4% ETOH in 0.5% Marcaine™ plain w/ Epinephrine. Patient tolerated this well.

Excision Foreign Body Pre-op diagnosis: Painful foreign body [right, left]

Post-op diagnosis: Same

Procedure: removal painful foreign body

Surgeon: Paul D. Brooks DPM

Assistants: none

Anesthesia: local

81

Hemostasis: Epinephrine in local anesthetic

Indications for procedure:

This patient presents for removal of painful foreign body. Patient states the discomfort is worsening and

limiting daily activities. All risks vs. benefits have been explained in great detail including but not limited

to risk of infection, numbness, wound dehiscence, re-occurrence of skin symptoms requiring further surgery. The patient understands these risks and elects to proceed with the procedure.

Procedure:

Patient was placed on the operating table in the supine position. The foot was anesthetized with 3mL of

a half and half mixture of 0.5% Marcaine™ with Epinephrine and 1% lidocaine plain in a regional block

fashion. The foot was then scrubbed, prepped and draped in the normal sterile fashion.

Attention was directed to the [HotSpots] of the [right, left] foot where a [1, 2, 3, 4, 5] cm skin incision

was made. The incision was deepened through subcutaneous tissues care being taken to avoid all vital

neural and vascular structures. All bleeders were ligated or bovied as necessary. The dissection was

performed [superficial, deep] to the level if the foreign body which was [found and removed, not found].

The wound was flushed with copious amounts of high pressure normal saline solution. The area was

once again inspected for completion of excision. The skin was re-approximated with 3-0 nylon in a simple interrupted technique.

A telfa and dry sterile dressing was applied. The patient was placed in a [post-op shoe, Aircast®,

protective dressing] and a follow-up visit was scheduled. Instructions were given to remain non-weight-bearing, keep foot elevated, and to avoid getting the foot wet under any circumstances.

RTC [1, 2, 3, 4, 5, 6, 7, 14] days.

Figure 25 – X-ray Examples of Foreign Body

82

Fracture - Initial Visit Patient: [Patient.Name] Account No: [Patient.AcctNo] Date: [Date]


complaint of a painful [right, left] [toe, foot, ankle] which has been present for [1, 2, 3, 4, 5, 6, 7] [days,

weeks, months, years]. Patient [has, has not] experienced trauma to the area. Patient [is, is not] able to

walk. Patient rates pain as [1,2,3,4,5,6,7,8,9,10]/10. Patient has been treating this condition with [pain

meds, nsaids, visit to urgent care/ED, immobilization, nothing just hoping it will resolve on its own, ice

packs]. Patient admits problem is [improving since onset, unchanged since onset, worsening since

onset].


Medications: [Meds]




ROS:


ENMT: [ENMT]



GI: [GI]

GU: [GU]








83

Examination: [The patient is appropriately dressed, articulate, awake, alert, and oriented x 3, appears their stated age and appears to be in good health.] [Vitals]

Dermatological: There is [ecchymosis, erythema, edema, heat, pain to palpation, prominent veins] of the

affected area.

Vascular: Dorsalis pedis and posterior tibial pulses are palpated at [1/4, 2/4, 3/4, 4/4] bilateral. Digital capillary fill time is <5 seconds bilateral.

Neurological: [Achilles and patellar reflexes are normal, brisk, and symmetrical bilateral.] [Epicritic

sensation including light touch are intact and without focal motor or sensory deficit bilateral lower

extremities.]

Musculoskeletal: Pain elicited on palpation of the [1st digit,2nd digit,3rd digit,4th digit,5th digit,1st

metatarsal,2nd metatarsal,3rd metatarsal,4th metatarsal,5th metatarsal, medial cuneiform, middle

cuneiform, lateral cuneiform, cuboid, navicular, talus, calcaneous, fibular malleolus, tibial malleolus,

fibular sesamoid, tibial sesamoid]. [MPJ ROM's are full and without crepitation.] [STJ ROM is full and

without crepitation.] [Ankle joint ROM is full and without crepitation with the knee extended.] There are no significant foot or ankle deformities bilaterally.

Radiographs: Weightbearing radiographs 3 views of the symptomatic foot reveal [occult fracture,

periosteal reaction, cortical disruption, compound fracture, callous formation, on-union, a suspicious

appearance of the periosteum of the bone that correlates well with the area of pain but no definite

fracture line appreciated] of the [1st digit,2nd digit,3rd digit,4th digit,5th digit,1st metatarsal,2nd

metatarsal,3rd metatarsal,4th metatarsal,5th metatarsal, medial cuneiform, middle cuneiform, lateral

cuneiform, cuboid, navicular, talus, calcaneous, fibular malleolus, tibial malleolus, tibial sesamoid, fibular sesamoid].

Assessment: [Fracture, Insufficiency fracture] [right, left] [1,2,3,4,5] [digit, metatarsal, medial cuneiform,

middle cuneiform, lateral cuneiform, cuboid, navicular, talus, calcaneous, fibular malleolus, tibial

malleolus, tibial sesamoid, fibular sesamoid].

Plan: I discussed the pathology, its likely cause, and options for treatment. I discussed conservative

versus aggressive therapy. Will immobilize the part with [Aircast® walker, fiberglass cast, modified Jones

cast, soft paste cast, ankle stirrup, post op shoe] completely refraining from unassisted walking. While

symptomatic, use of an ice pack twice a day for 10-15 minutes until swelling has resolved.

[Recommended patient wear the assistive device every day as the structure of the foot allows.] Oral instructions and education concerning compliance given. Surgical correction [discussed, not discussed].

RTC in [1, 2, 3, 4, 6, 12] weeks for serial x-rays.

84

Figure 26 – Antenor/Posterior View of Fibula Fracture

Figure 27 – Lateral and Antenor/Posterior View of Fibula Fracture

85

Fracture - Follow-up Visit Patient: [Patient.Name] Account No: [Patient.AcctNo] Date: [Date]

Subjective: Patient presents today for follow-up for fracture care. Patient [has, has not] been compliant in the immobilization device. States the pain is [improved, unchanged, worsened].

PMH, PSH, Meds: Unchanged since last visit.


Musculoskeletal: There is pain on palpation of the [digit, metatarsal, medial cuneiform, middle


tibial sesamoid, fibular sesamoid]. There are no other significant foot or ankle deformities appreciated bilaterally.

Dermatological: There is [edema, erythema, ecchymosis, break in the skin] at the area. No varicosities,

telangiectasias, pigmented lesions or signs of venous stasis changes to bilateral lower

extremities. Adequate fat padding to the inferior aspect of each foot appreciated.

Radiology: [2, 3] views of the symptomatic foot reveals [no gross boney abnormalities, occult fracture, periosteal reaction].

Assessment: Fracture [right, left] [1st, 2nd, third, 4th, 5th] [digit, metatarsal, medial cuneiform, middle


tibial sesamoid, fibular sesamoid].


[continued course of treatment for an additional, discharge from care] [1week, 2 weeks, 3 weeks, 4

weeks, 6 weeks]. If patient has not realized significant long-term benefit from these conservative

measures I recommended surgical intervention. Patient has been advised of the approximate disability






biomaterials, over-correction, under-correction with recurrence of the deformities, continued pain, and


ask questions which were answered satisfactorily to the best of my ability. The patient voiced no concerns and will consider all these options and schedule accordingly.

Gait Analysis

A gait analysis was performed today which showed [no gait abnormalities*,excessive pronation of ??

foot, excessive supination of ?? foot, excessive inversion of ?? foot, excessive eversion of ?? foot, a limb

length discrepancy of ?? leg]. [Abnormal, Normal*] angle and base of gait was observed. Abductory

twist [was, was not*] noted. Extensor substitution [was, was not*] found. Flexor stabilization [was*,

86

was not] observed. Heel contact was [normal*, abnormal], [left, right, bilateral*]. [Normal*, Abnormal]

heel lift was observed [left, right, bilateral*]. [Normal*, Abnormal toe purchase observed [left, right,

bilateral*]. Gait [appeared, did not appear*] antalgic. Arm swing is [equal*, greater on left, greater on right].

Figure 28 – Illustration of Gait Analysis

Gout - Initial Visit Patient: [Patient.Name] Account No: [Patient.AcctNo] Date: [Date]


complaint of a [sudden, gradual] onset of deep aching and burning type pain of the [right, left] [great

toe, lessor toe, midfoot, Achilles tendon, rearfoot, ankle] joint area. There [has, has not] been trauma to

the area recently. It is especially painful [with weight-bearing, with activities, when walking barefoot,

when walking on hard surfaces]. It began [1, 2, 3, 4, 5, 6,??] [days, weeks, months] ago. The pain is

alleviated by [nothing, cushioned foot wear, icing, heat, stretching, messaging, OTC topical analgesics,

OTC oral analgesics, prescription NSAIDs, narcotics]. The patient [has, has not] had a similar condition in

the past. There [is, is not] a family history of gout. Last seen by PCP, [Patient.PrimaryPhysician] on

[Patient.DateLastSeen].


Medications: [Meds]



87


ROS:


ENMT: [ENMT]



GI: [GI]

GU: [GU]









Musculoskeletal: Pain to palpation of the [1st MPJ, 2nd MPJ, 3rd MPJ, 4th MPJ, 5th MPJ, midfoot joint(s),

rearfoot joint(s), ankle joint, Achilles tendon area]. Range of motion of the joint in question is [guarded,

full, limited] and [with, without, unable to access] crepitation.

Dermatological: There is [minimal, moderate, severe] tenderness with palpation of the area. The joint

area is [red, hot, swollen, not showing signs relative to the complaint]. Skin turgor is [normal, tight and

shiny, peeling]. Varicose veins and telangiectasia are [not present, mild, moderate, severe]. The skin is

otherwise clear. No signs of infection. No pigmented lesions.

Neurological: Epicritic sensations are intact. Gross motor function intact. Gait [is, is not, is slightly] antalgic.

Vascular: Pedal pulses are [intact, unable to determine]. Hair growth is [present, absent] on the feet. CFT < 3 seconds to the toes. No cyanosis seen.

Assessment: [acute, chronic] gouty arthritis [1st MPJ, lessor MPJ, midfoot, rearfoot, ankle joint] [right,

left]

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Plan: I discussed the nature of the problem and treatment options with the patient. At this point I [sent

for, will hold off on] a uric acid test. I placed in a [post op shoe, Aircast®, normal shoes, crutches].

Discussed diet and the things to stay away from including, red meat, shrimp, tomato products, red wine

and beer. The patient wants to [adjust diet before further testing, have the blood test and will present

to the office for results, have the blood test and we will call with the results, start on uric acid lowering

meds as the problem is recurrent, continue uric acid meds].

RTC [when results come in,1 week,2 weeks,4 weeks,12 weeks, prn].

Gout - Follow-Up Visit Patient: [Patient.Name]

Account No: [Patient.AcctNo] Date: [Date]

[Patient.FirstName] is a [Patient.Age] year old [Patient.Gender] who presents for follow up of gout of

the [right, left] foot in the [great toe, lessor toe, midfoot, Achilles tendon] joint area. States the problem is [improving, resolved, worsening, returned].

PMHx: [PMH]

PSHx: [PSH]

Medications: [Meds]


Social Hx: [Social History]

Review of Systems: [ROS]

Examination: Alert & Oriented x 3. Presents in no acute distress.

Musculoskeletal: Pain to palpation of the [1st MPJ, 2nd MPJ, 3rd MPJ, 4th MPJ, 5th MPJ, midfoot joint(s),

rearfoot joint(s),ankle joint, Achilles tendon area] is [gone, mildly present, persists]. Range of motion of

the joint in question is [guarded, full, limited] and [with, without, unable to access] crepitation.

Dermatological: There is [minimal, moderate, severe, no] tenderness with palpation of the area of the

[right, left] foot. The joint is [red, hot, swollen, not showing signs relative to the complaint, quiescent].

Skin turgor is [normal, tight and shiny, peeling]. Varicose veins and telangiectasia are [not present, mild, moderate, severe]. The skin is otherwise clear. No signs of infection. No pigmented lesions.

Neurological: Epicritic sensations are intact. Gross motor function intact. Gait is [not, slightly] antalgic.

Vascular: Pedal pulses are [intact, unable to determine]. Hair growth is [present, absent] on the feet.

CFT < 3 seconds to the toes. No cyanosis seen.

89

Assessment: gouty arthritis [1st MPJ, lessor MPJ, midfoot, rearfoot] [right, left] [improved, worsening, resolved]

Plan: I discussed the nature of the problem and treatment options with the patient. At this point [we will

watch to see how long it takes to return, continue meds on a daily basis to control uric acid elimination,

adjust diet to prevent recurrence]. For shoe wear I advised [post op shoe, Aircast®, normal shoes,

crutches]. Discussed diet and the things to stay away from including, red meat, shrimp, tomato

products, red wine and beer.

RTC [1,2,3,4,5,6,7,8,9,10,11,12,prn] weeks.

Figure 29 - Gout in Left Foot

Hallux Rigidus - Initial Visit Patient: [Patient.Name] Account No: [Patient.AcctNo] Date: [Date]


painful deformity to the great toe region. Pain is associated with [closed toed shoe gear, walking,

exercising, normal daily activities] and has not responded to [self-care, soaks, rest, OTC padding] with

shoe gear changes. Patient [has, has not] experienced this or similar condition previously and [denies,

90

admits] recent trauma or inciting events. Patient admits [no known cause, is an athlete and occurred

over time, a heavy object dropped from a height, remembers jamming the toe against an object,

remembers an MVA which started the problem]. Problem has been present for several [days, weeks, months, years]. [The patient does have a family history of foot deformity].


Medications: [Meds]




ROS:


ENMT: [ENMT]



GI: [GI]

GU: [GU]









Vascular: Dorsalis pedis and posterior tibial pulses are [1, 2, 3, 4]/4 bilateral. Capillary filling time with

the leg elevated is [<5, 5, >5] seconds at the level of the digital tufts bilateral. There are no ischemic skin

changes evident bilateral lower extremities.

91

Musculoskeletal: There is pain on palpation of the [right, left] great toe joint. [Positive, Negative] axial

grind test evident to the [right, left, bilateral] first MTPJ with [mild, moderate, severe] synovitis and

effusion evident. There is [<20, 20-25, 25-30, 30-35, >35] degrees dorsiflexion and [<20, 20-25, 25-30,

30-35, >35] degrees plantarflexion available [right, left, bilaterally]. Manual plantarflexion of the 1st MPJ results in [increased, decreased, no change in] ROM.


bilateral. Epicritic sensation including sharp-dull, light touch, proprioception, 2-point discrimination (<



are down-going toes and a negative clonus bilateral. Normal muscle mass appreciated to both the lower extremity and foot bilateral. There [is, is not] pain on palpation of the [right, left] great toe joint.

Dermatological: [There is erythema consistent with friction-induced shoe-gear irritation to the first MTPJ, no sign relative to complaints.]

Radiographs: Weightbearing radiographs of the [right, left, bilateral] foot reveal a hallux rigidus

deformity with [asymmetrical joint space narrowing, dorsal exostosis formation, lateral exostosis

formation, medial exostosis formation, sesamoid-metatarsal degeneration, equinus of the hallux,

flattening to the metatarsal head, elevatus of the 1st metatarsal] but no evidence of tumor, fracture, or cystic changes.

Impression: Symptomatic Hallux Rigidus [right, left, bilateral]

Plan: I have discussed the treatment options with the patient, and have discussed proper shoe gear. I

have discussed conservative treatments such as injections, shoe inserts and modification and EPAT

radial pulse wave therapy as well as more aggressive surgical procedures such as spur reduction and

decompressive procedures. At this time the patient elects to be [conservative, aggressive]. I discussed

shoe gear changes and range of motion exercises to keep the ROM from continuing to decrease. I

explained this is a progressive deformity and will likely get worse with time. She seems to understand. All questions were answered to my ability.

RTC [1 week,2 weeks,4 weeks,6 weeks,12 weeks,36 weeks, prn]

92

Figure 30 –Photograph and X-ray of Hallux Rigidus deformity

Hallux Rigidus – Follow-up - Steroid Injection Patient: [Patient.Name] Account No: [Patient.AcctNo] Date: [Date]

Subjective: Patient presents today in follow-up hallux limitus deformity to the [right, left, bilateral] great

toe joint. Patient admits [0%, 10%, 20%, 30%, 40%, 50%, 60%, 70%, 80%, 90%, 100%] improvement.

Patient [is, is not] compliant with instructions this far. [Desires, Does not desire] to continue this line of treatment.


Objective: The patient's neurovascular status of bilateral lower extremity is unchanged since the last visit.

Musculoskeletal: There [is, is not] pain on palpation of the [right, left, bilateral] great toe at the level of

the MTPJ. The toe has remained in a [contracted, non-contracted] position. There [is, is not] crepitation

on attempted ROM. [There are no other significant foot or ankle deformities appreciated bilateral]. Joint effusions are [present, absent].

Dermatological: There [is, is not] fixed erythema overlying the first MTPJ consistent with shoe-gear-

related irritation. Otherwise, there is no evidence of edema, ecchymosis, open lesions, interdigital

maceration or signs of bacterial or fungal infection bilateral lower extremities. No varicosities,

telangiectasias, pigmented lesions or signs of venous stasis changes bilateral lower

extremities. Adequate fat pad to the plantar aspect of each foot is evident.

Assessment: Symptomatic Hallux Rigidus, [right, left, bilateral], [with Hallux Equinus].

93

Plan: I have discussed the treatment options once again with the patient and have recommende d

[continued use of current treatment, change the treatment based on the progress thus far]. They will

continue ROM exercises and continue wearing shoes that fit properly and accommodate the problem. We will see them back in 2 weeks’ time or sooner if problems arise.

Joint Injection

An injection of the [left, right, bilateral] [1st MTPJ, 2nd MTPJ, 3rd MTPJ, 4th MTPJ, 5th MTPJ, MTJ, STJ, ankle

joint] was performed this date to [reduce symptoms*, reduce swelling, reduce pain]. The involved joint

was prepped with Betadine and ethyl chloride was used as a topical anesthetic. [?? cc 1% Lidocaine, ??

cc 2% Lidocaine, ?? cc 0.5% Marcaine™, ?? cc Decadron, ?? cc Depomedrol, ?? cc Triamcinolone, ?? cc Dexamethasone] was then administered.

Figure 31 - Illustration of Joint Injection

Hallux Valgus

The 1st metatarso-phalangeal joint is [rectus, deviated, subluxed] in the [frontal, tranverse, sagittal]

planes. There is [full, limited, rigid] range of motion. There is pain to palpation of the [medial eminence,

joint line dorsally, joint line medially, joint line laterally]. There [is, is not crepitation appreciated]. There

[are, are not] skin changes at the medial eminence at risk of ulceration.

94

Figure 32 – Hallux Valgus of the Left Foot

Hammertoe - Initial Visit Patient: [Patient.Name] Account No: [Patient.AcctNo] Date: [Date]

Chief Complaint: This [Patient.Age] year old [Patient.Gender] presents today with complaint of [a

chronic callous formation of the toe(s),a painful burning sensation in the toe, deformed toes, toes

rubbing in shoes, hammer toes]. Symptoms [has, has not] responded to [self-debridement, soaks, OTC

padding, shoe gear changes]. Patient [denies, admits] trauma or inciting events. Last seen by PCP,

[Patient.PrimaryPhysician] on [Patient.DateLastSeen].


Medications: [Meds]




95

Review of Systems:


ENMT: [ENMT]



GI: [GI]

GU: [GU]








Examination: The patient is appropriately dressed, articulate, awake, alert, and oriented x 3, appears their stated age and appears to be in [good, fair, poor] health. Their vitals are as follows: [Vitals].

Vascular: Dorsalis pedis pulses are [non-palpable, diminished, normal, strong, bounding] b/l and

posterior tibial pulses are [non-palpable, diminished, normal, strong, bounding] b/l. Capillary filling time

with the leg elevated is [<3,3,>3] seconds at the level of the digital tufts bilaterally. Hair [is, is not] present on the feet and toes.

Musculoskeletal: There is [no pain, pain] on palpation of the [HotSpots]. The toe(s) are [flexible and

reducible, semi rigid and partially reducible, rigid and nonreducible, subluxed, dislocated off the MTP

joint]. There is contracture present at the [sagittal plane, transverse plane, MPJ, PIPJ, DIPJ, IPJ]. Gait

analysis reveals [flexor stabilization, flexor substitution, extensor substitution, no observable cause for the deformity].

Neurological: [Deep tendon reflexes including Achilles and Patellar are normal, brisk, and symmetrical

bilateral.] [Epicritic sensation including sharp-dull, light touch, proprioception, 2-point discrimination (<


monofilament) are intact and without focal motor or sensory deficit bilateral lower extremities.] [There

are down-going toes and a negative clonus bilateral. Normal muscle mass appreciated to both the lower

96

extremity and foot bilaterally.] [Neurological disease state present evidenced by tight extensors and a high arched foot type.]

Dermatological: There are hyperkeratotic lesions [HotSpots]. Evidence of [edema, erythema, ingrown

toenail, abscessed toenail, thickened toenails, distal digital trauma, ecchymosis, open lesions, kissing corns or soft corns, interdigital maceration, signs of bacterial infection, signs of fungal infection].

Radiographs: A [X-Ray 2 Views, X-Ray 3 Views, MRI, CT Scan, Three Phase Bone Scan, WDC Labeled scan]

was reviewed today. The results show [exostotic bone, arthritis, joint subluxation, boney deformity,

abnormally elongated phalanx, abnormally elongated metatarsal, no abnormal findings] with respect to the following area: [hotspots].

Impression: Symptomatic hammer digit(s) syndrome [hotspots].

Plan: I have discussed the treatment options with the patient. I have discussed conservative vs.

aggressive procedures to correct or palliate this condition. The plan at this point is to [monitor the

deformity for worsening symptoms, palliate this condition, correct the problem with bracing/padding,

correct this problem surgically]. Treatment today consisted of: [debridement lesion(s) partial thickness

of callous, Debridement lesion full thickness to subcutaneous tissues, Debridement lesion to deep

tendon or bone, Dispensed crescent pad(s) to offload the distal toe(s), Dispensed a darco toe alignment

splint(s),Dispensed silicone/foam toe spacer(s)] which patient will reapply on a daily basis. [Instructions

and face to face instruction was performed with the use of all aids and devices.] Recommended: [shoe

gear adjustments based on visual inspection and/or measurements taken in office, continue with

current shoe gear, new shoe gear, extra depth shoes diabetic extra depth shoe gear with custom multi-

layed plastizote insoles]. Surgical recommendations include [flexor tenotomy, an arthroplasty, an

arthrodesis, an amputation] of the [hallux, second, third, fourth, fifth] toe to correct the condition. The

patient was given the opportunity to ask questions which were answered to the best of my ability. [The

patient will consider all these options.] [The patient desires to have the condition corrected surgically

and will schedule for procedure.] [The patient will change shoe gear based on my recommendati ons.]

RTC [as needed,1 week, 2 weeks, 4 weeks, 12 weeks, 1 year].

97

Figure 33 – Before and After Demonstration of Hammertoe Surgery

Hammertoe - Initial Visit - Arthroplasty Patient: [Patient.Name] Account No: [Patient.AcctNo] Date: [Date]

Chief Complaint: This [Patient.Age] year old [Patient.Gender] presents today with complaint of chronic

callous formation overlying a [right, left, bilateral] [first, second, third, fourth, fifth] toe deformity with

pain associated with closed toed shoe gear. Pain has not responded to [self-debridement, soaks, OTC

padding, shoe gear changes]. Patient has not had a similar condition previously and denies any recent trauma or inciting events.


Medications: [Meds]




Review of Systems:


98

ENMT: [ENMT]



GI: [GI]

GU: [GU]









Vascular: Dorsalis pedis and posterior tibial pulses are [non-palpable, diminished, normal, strong,

bounding] and graded [0, 1, 2, 3, 4] bilateral. Capillary filling time with the leg elevated is [<5, 5, >5]

seconds at the level of the digital tufts bilaterally. There are no ischemic skin changes evident bilateral lower extremities.

Musculoskeletal: There is pain on palpation of the proximal phalanx to the [right, left, bilateral] [1st,

2nd, 3rd, 4th, 5th] toe where a hyperkeratotic lesion is evident. The toe is contracted in a semi-rigid

nature at the PIPJ with slight contracture evident to the MTPJ. There are no other significant foot or ankle deformities appreciated bilaterally.


bilateral. Epicritic sensation including sharp-dull, light touch, proprioception, 2-point discrimination (< 12

mm at level of hallux tuft), vibration (128 MHz tuning fork) and protective threshold (10.0 gram


are down-going toes and a negative clonus bilaterally. Normal muscle mass appreciated to both the

lower extremity and foot bilateral. There is pain on palpation of the toe in the region of the hyperkeratotic lesion.

Dermatological: There is a deep seated hyperkeratotic lesion overlying the PIPJ of the toe which, after

debridement, does not reveal any verruca-type tissue, retained foreign bodies, or cardinal signs of

infection. Otherwise, there is no evidence of edema, erythema, ecchymosis, open lesions, interdigital


99

telangectasias, pigmented lesions or signs of venous stasis changes bilateral lower extremities. Adequate fat padding to the inferior aspect of each foot appreciated.

Radiographs: Weight-bearing radiographs of the symptomatic [right, left] foot with comparison views of

the contralateral foot reveal a contracted [1st, 2nd, 3rd, 4th, 5th] toe at the PIPJ level with some sagittal

plane contracture at the level of the MTPJ as well. The proximal phalanx head to the toe is enlarged with a moderate exostosis but no evidence of tumor, fracture, or cystic changes.

Impression: Symptomatic hammer digit syndrome digit: [first, second, third, fourth, fifth] toe.

Plan: I have discussed the treatment options with the patient and have debrided the lesion full

thickness, dispensed some toe strapping/silicone padding which patient will reapply on a daily basis,

recommended use of Vaseline or similar product to decrease friction, and stretched shoes as

well. Should these measures fail I recommended an arthroplasty of the PIPJ to the [hallux, second, third,

fourth, fifth] [right, left] toe to correct the condition. Patient has been advised of the approximate

disability involved for these procedures, and the alternatives of care available including continued

conservative care. The patient understands that if surgical procedures are performed, there are risks

and complications that could occur, including but not limited to: hematoma formation, seroma

formation, development of a DVT or phlebitis, infection, painful scar tissue formation, limited motion,

delayed-union, non-union, mal-union, reaction to implanted biomaterials, over-correction, under-

correction with recurrence of the deformities, continued pain, and the possibility that future surgery

may need to be performed. The patient was given the opportunity to ask questions which were

answered satisfactorily to the best of my ability. The patient voiced no concerns, will consider all these

options, and schedule accordingly. We will see them back on a PRN basis or sooner should problems

arise.

Figure 34 – X-Ray of Before and After Hammertoe Surgery

100

Hammertoe – Follow-up Patient: [Patient.Name] Account No: [Patient.AcctNo] Date: [Date]

Subjective: Patient presents today for follow-up of a recurrent and chronic callous formation overlying a

[first, second, third, fourth, fifth] toe deformity with pain associated with closed-toe shoe gear. Patient

did well with debridement and padding but has noticed a significant recurrence of the callous f ormation

and discomfort even with the changes in shoe gear and padding.


Objective: The patient's neurovascular status bilateral lower extremity is unchanged since last visit.

Musculoskeletal: There is pain on palpation of the proximal phalanx of the [right, left, bilateral] [hallux,

second, third, fourth, fifth] toe where a hyperkeratotic lesion is evident. The toe has remained in a

contracted position and is semi-rigid at the PIPJ with slight contracture evident to the MTPJ. There are

no other significant foot or ankle deformities appreciated bilaterally.

Dermatological: There is a deep seated hyperkeratotic lesion overlying the PIPJ of the toe which, after

debridement, does not reveal any verruca type tissue, retained foreign bodies, or cardinal signs of

infection. Otherwise, there is no evidence of edema, erythema, ecchymosis, open lesions, interdigital


telangiectasias, pigmented lesions or signs of venous stasis changes bilateral lower extremities. Adequate fat padding to the inferior aspect of each foot appreciated.

Assessment: Symptomatic hammer digit syndrome [right, left, bilateral] [hallux, second, third, fourth,

fifth] toe.

Plan: I have discussed the treatment options once again with the patient and have debrided the lesion

full thickness. Also recommended continued use of the silicone padding/strapping dispensed at previous

visit, recommended use of Vaseline or similar product to decrease friction, and have once again

stretched shoes as well. Since patient has not realized significant long-term benefit from these

conservative measures I recommended the surgery previous discussed at last visit. Patient has been

advised of the approximate disability involved for these procedures. In addition, the patient has been

advised as to the alternatives of care, including continued conservative care as well as surgical

procedures. The patient understands that if surgical procedures are performed, there are risks and

complications that could occur, including but not limited to: hematoma formation, seroma formation,

development of a DVT or phlebitis, infection, painful scar tissue formation, limited motion, delayed

union, nonunion, malunion, reaction to implanted biomaterials, over-correction, undercorrection with

recurrence of the deformities, continued pain, and the possibility that future surgery may need to be

performed. The patient was given the opportunity to ask questions which were answered satisfactorily

to the best of my ability. The patient voiced no concerns and will consider all these options and schedule accordingly.

101

Heel Exam - Ortho Exam

Pain elicited on palpation of the [medial heel, plantar medial heel*, mid plantar arch, distal plantar arch,

posterior heel posterior-lateral heel, posterior-medial heel] near origin of the intrinsic musculature and

plantar fascia, but no pain on medial-lateral compression of the calcaneus. There [is, is not] a tight

medial band of the plantar fascia to palpation with the toes extended. The Achilles tendon has [full

ROM, limited extension with the knee locked, limited extension with the knee unlocked]. [Palpable Haglunds deformity present.][Palpable enthesophyte present.]

Joint Injection

An injection of the [left, right, bilateral] [1st MTPJ, 2nd MTPJ, 3rd MTPJ, 4th MTPJ, 5th MTPJ, MTJ, STJ,

ankle joint] was performed this date to [reduce symptoms*, reduce swelling, reduce pain]. The involved

joint was prepped with Betadine and ethyl chloride was used as a topical anesthetic. [?? cc 1%

Lidocaine, ?? cc 2% Lidocaine, ?? cc 0.5% Marcaine™, ?? cc Decadron, ?? cc Depomedrol, ?? cc Triamcinolone, ?? cc Dexamethasone] was then administered.

Figure 35 – Demonstration of a Joint Injection

102

Osteoarthritis - Initial Visit Patient: [Patient.Name] Account No: [Patient.AcctNo] Date: [Date]

Chief Complaint: This [Patient.Age] year old [Patient.Gender] presents today with complaint of a painful

[right, left, right and left] [foot, ankle] which has been present for [days, weeks, months, years]. Patient

[has, has not] experienced recent trauma. Patient [has, has not] experienced previous trauma. Patient

[has, has not] noticed a malposition of the feet as a result of the condition. Patient rates pain as

[1,2,3,4,5,6,7,8,9,10]/10, (10 being the worst). Patient has been treating this condition with [NSAIDS, pain killers, shoe modifications, immobilization and non-weight-bearing, bracing, benign neglect].


Medications: [Meds]




Review of Systems:


ENMT: [ENMT]



GI: [GI]

GU: [GU]








103


Dermatological: There is [ecchymosis, erythema, edema, heat, pain to palpation] of the affected area of

the [foot, ankle]. No varicosities, telangiectasias, pigmented lesions or signs of venous stasis changes

bilateral lower extremities. [Adequate, In-adequate] fat padding to the inferior aspect of the feet. Skin is normal color and turgor otherwise.

Vascular: Dorsalis pedis pulses are [0,1,2,3,4]/4 right and [0,1,2,3,4]/4 left. Posterior tibial pulses are

[1,2,3,4]/4 right and [0,1,2,3,4]/4 left. Digital capillary fill time is [immediate, delayed, normal] bilaterally. There are no ischemic skin changes evident in either lower extremity.





are downgoing toes and a negative clonus bilateral. [Normal, Atrophic] muscle mass appreciated to both

the lower extremity and foot bilateral. The patient [can, cannot] heel and toe walk with ease as well as

arise from a seated position unassisted. Percussion of the tarsal tunnel and porta pedis [negative, positive] for Tinnel`s or Valieux sign [right, left, bilateral].

Musculoskeletal: Pain elicited on palpation of the [joints of the midfoot, joints of the forefoot, ankle, STJ,

MTJ, M-C joints, 1st MPJ, 2nd MPJ, 3rd MPJ, 4th MPJ, 5th MPJ, digital interphalangeal joints] of the [right,

left, right and left] [foot, feet]. The pain is more severe on the [right, left] vs the [right, left]. The [right,

left, right and left] Achilles tendon [has, has no] palpable abnormality, has [limited, normal] ROM with

knees extended, [limited, normal] ROM with knees flexed. There [is, is no] fusiform swelling or pain in

the watershed area. Posterior tibial tendon strength graded at [1, 2, 3, 4, 5]/5 [with, with no] pain to

palpation or exertion against resistance. Knees appear [rectus, internally rotated, externally rotated]

[right, left, bilaterally]. There [are, are no] other significant foot and/or ankle deformities noted [right,

left, bilaterally].

Radiographs: Weightbearing radiographs [2,3] views of the symptomatic [ foot, ankle] reveal [joint space

loss, sub-chondral eburnation, cyst formation, osteophytosis, subluxation, uncovering of the talus on the

navicular, misalignment, malalignment, fibrous ankylosis, intra-articular bodies, low calcaneal inclination

angle, normal calcaneal inclination angle, metadductus] of the [1st, 2nd, 3rd, 4th, 5th] [IPJ, PIPJ, DIPJ, MPJ,

midfoot, M-C joint, N-C joint, STJ, T-N joint, ankle, ankle joint medially, ankle joint laterally]. No fractures

or dislocations were noted. No soft tissue abnormalities were noted. Radiographic Impression: [mild,

moderate, severe] [localized, generalized, widespread, chronic, recent onset] degenerative joint disease as noted above.

Assessment: [Mild, Moderate, Severe] degenerative joint disease of the [right, left, bilateral] [IPJ, PIPJ, DIPJ, MPJ, midfoot, M-C joint, N-C joint, STJ, T-N joint, ankle, medial ankle joint, lateral ankle joint].

Treatment: I discussed the pathology, its likely cause, and options for treatment. I discussed

conservative versus aggressive therapy. Will [immobilize, mobilize] the foot with [aircast walker,

fiberglass cast, modified Jones cast, Soft paste cast, ankle stirrup, orthotics, soft tennis shoes, extra

depth shoes] completely refraining from unassisted walking. Recommend [wear the device(s) every day

104

as the structure of the foot allows, surgical correction, injection therapy, oral therapy, topical therapy]. Oral and written instructions given regarding compliance and prognosis.

RTC [1, 2, 3, 4, 6, 12] [weeks, days, prn] for follow-up.

Figure 36 – Illustration of Osteoarthritis

Osteoarthritis Follow-up Patient: [Patient.Name] Account No: [Patient.AcctNo] Date: [Date]

Subjective: Patient presents today for follow-up for arthritis care. Patient [has, has not] been compliant

and adhered to the current treatment plan. States the pain is [improved, unchanged, worsened] by [10,20,30,40,50,60,70,80,90,100]%.



Musculoskeletal: The patient presents [walking, with a walker, with antalgic gait, limping]. There [is, is

no, is still some, is still moderate, is still severe] pain on palpation of the [[PIPJ, MPJ, midfoot, M-C joint,

N-C joint, STJ, T-N joint, ankle joint medially, ankle joint laterally].

Dermatological: There is [erythema, edema, ecchymosis, no signs of inflammation] overlying the symptomatic area.

105

Radiology: [views not taken at this visit, no changes from previous views, worsening changes appreciated compared to previous views

Assessment: Osteoarthritis [right, left] [1st, 2nd, 3rd, 4th, 5th] [PIPJ, MPJ, midfoot, M-C joint, N-C joint, STJ,

MTJ, T-N joint, ankle joint medially, ankle joint laterally]


[continued course of treatment as planned with additional injections, cessation of current injection

therapy, shift away from current therapy and try alternative forms of treatment]. [I discussed injection

therapy for pain relief is simply a relief of symptoms and not a cure.] Patient [desires, does not desire]

to have an injection. If patient has not realized significant long-term benefit from these conservative

measures, we discussed alternative forms of treatment such as surgical intervention, bracing, custom

orthotics]. Patient has been advised of the risks and benefits for these alternative measures and or

procedures including conservative care].The patient was given the opportunity to ask questions which

were answered satisfactorily to the best of my ability. The patient voiced no concerns and will consider

all these options.

Plan: Patient was injected into and around the symptomatic joint with [1cc dexamethasone phosphate

4mg/mL, 10mg of Kenalog®, 40mg of Kenalog®] in local anesthetic solution. Ultrasound performed at 1 watt for 15 minutes. Patient tolerated this very well.

Peroneal Tendonitis Patient: [Patient.Name] Account No: [Patient.AcctNo] Date: [Date]


[right, left] foot/ankle which has been present for [days, weeks, months, years]. Patient [has, has not]

experienced recent trauma. The pain is [improving, worsening, unchanged] since onset. Patient has

been treating this condition with [NSAIDS, shoe modifications, immobilization and non-weight-bearing, benign neglect, visits to other physicians, injections].


Medications: [Meds]




ROS:


106

ENMT: [ENMT]



GI: [GI]

GU: [GU]









Dermatological: There is [ecchymosis, erythema, edema, heat, pain to palpation] of the affected area.

Vascular: Dorsalis pedis and posterior tibial pulses are palpated at [1, 2, 3, 4]/4 bilateral. Digital capillary fill time is <5 seconds bilateral. There are no ischemic skin changes evident bilateral lower extremities.







position unassisted. Percussion of the tarsal tunnel and porta pedis [negative, positive] for Tinnel's or

Valieux sign [right, left, bilateral].

Musculoskeletal: Pain elicited on palpation of the peroneal tendon complex in the [watershed area,

insertion into the styloid process, above the level of the malleolus, under the curvature of the cuboid,

deep in the subcuboidal space]. It has [no palpable abnormality, fusiform swelling, palpable defect in the

tendon substance]. Strength of the peroneus longus tendon graded as [5, 4, 3, 2, 1]/5. Strength of the

peroneus brevis tendon is [1, 2, 3, 4, 5]/5. Ski jump maneuver is [positive, negative] for subluxation.

There [is, is not] pain to palpation of the peroneal trochlea, which [is, is not] enlarged. Intact posterior

tibial tendon, strength graded at 5/5. Ankle joint ROM is [normal, limited] with the knee extended [bilateral, right, left]. There are no other significant foot or ankle deformities bilaterally.

107

Radiographs: Weightbearing radiographs [2, 3] views of the symptomatic [foot, ankle] reveals [no gross

boney abnormalities, enthesophytes, calcifications within the tendon, accessory ossicle in the peroneus

longus tendon]. Tendon contour [is, is not] abnormal.

Assessment: [Peroneal tendonitis, peroneal tendonosis, hypertrophic peroneal trochlea, Os peroneum]


versus aggressive therapy. I will [mobilize, immobilize] the tendon with [Airheel™, Aircast® walker,

fiberglass cast, orthotic device, modified Jones cast, Soft paste cast, ankle stirrup ,supportive athletic

shoes]. While symptomatic use of an ice pack twice a day for 10-15 minutes as needed. Rx options were

discussed, patient cautioned regarding GI ulcer risk. Recommend wear the device every day as the structure of the foot allows. Oral and written instructions given regarding compliance.

RTC in [1, 2, 3, 4, 6, 12] weeks.

Figure 37 – Illustration of Peroneal Tendonitis

Pes Planus Patient: [Patient.Name] Account No: [Patient.AcctNo] Date: [Date]

Chief Complaint: Patient is a [Age] year old [Sex] who presents today with complaint of a painful [ right,

left] [foot, ankle] which has been present for [days, weeks, months, years]. Patient [has, has not]

108

experienced recent trauma. Patient [has, has not] noticed a malposition of the feet. Patient [is able to

participate at school physical education but is fatigued afterwards, notices fatigue after a time at work,

does not have any fatigue problem]. Patient rates pain as [1,2,3,4,5,6,7,8,9,10]/10, (10 being the

worst). Patient has been treating this condition with [NSAIDS, shoe modifications, immobilization and non-weight-bearing, bracing].


Medications: [Meds]




ROS:


Eyes: [Eyes]




GI: [GI]

GU: [GU]








Examination: The patient is appropriately dressed, articulate, awake, alert, and oriented x 3, appears their stated age and appears to be in good health.

109

Dermatological: There is [ecchymosis, erythema, edema, heat, pain to palpation] of the affected area of

the medial foot. No varicosities, telangiectasias, pigmented lesions or signs of venous stasis changes

bilateral lower extremities. [Adequate, In-adequate] fat padding to the inferior aspect of the feet. Skin is normal color and turgor otherwise.

Vascular: Dorsalis pedis and posterior tibial pulses are palpated at [1, 2, 3, 4]/4 bilateral. Digital capillary

fill time is [immediate, delayed] bilateral. There are no ischemic skin changes evident bilateral lower

extremities.







arise from a seated position unassisted. Percussion of the tarsal tunnel and porta pedis [negative, positive] for Tinnel`s or Valieux sign [right, left, bilateral].

Musculoskeletal: Pain elicited on palpation of the [joints of the midfoot, navicular tuberosity, lateral foot

and ankle, sinus tarsi]. The achilles tendon [has no palpable abnormality, has limited rom with knees

straight and flexed, fusiform swelling in the watershed area]. Posterior tibial tendon, strength graded at

[1, 2, 3, 4, 5]/5 and [with, without] pain. Knee appear [rectus, internally rotated, externally rotated]. There [are, are not] other significant foot and/or ankle deformities [right, left, bilaterally].

Radiographs: Weightbearing radiographs [2,3] views of the symptomatic foot reveal [joint space loss,

sub-chondral eburnation, cyst formation, osteophytosis, subluxation, uncovering of the talus on the

navicular, misalignment, malalignment, fibrous ankylosis, intra-articular bodies, low calcaneal inclination

angle, normal calcaneal inclination angle, metadductus] of the [1st, 2nd, 3rd, 4th, 5th] [PIPJ, MPJ, midfoot, M-C joint, N-C joint, STJ,T-N joint, ankle joint medially, ankle joint laterally].

Assessment: Pes plano valgus [right, left]


versus aggressive therapy. Will [immobilize, mobilize] the part with [Aircast® walker, fiberglass cast,

modified Jones cast, Soft paste cast, ankle stirrup, orthotics] completely refraining from unassisted

walking. Recommend [wear the device every day as the structure of the foot allows, surgical correction].

Oral and written instructions given regarding compliance and prognosis.

RTC in [1, 2, 3, 4, 6, 12] weeks.

110

Figure 38 – Illustration of Pes Planus

Figure 39 – Patient with Pes Planus

111

Plantar Fasciitis - Initial Visit Patient: [Patient.Name] Account No: [Patient.AcctNo] Date: [Date]


[right, left, bilateral] heel(s). Patient states the problem has been present for [1mo., 2mos., 3mos.,

4mos., 5mos., 6mos., 1 year, 2 years, over 2 years]. Patient rates pain as [1, 2, 3, 4, 5, 6, 7, 8, 9, 10]/10,

(10 being the worst). Patient admits to [pain after periods of rest, pain in the morning upon arising out

of bed, no aggravating activities, exacerbated by walking for exercise, walking barefoot at home,

standing at work, high activity at work, up and down out of a chair at work, high-impact exercises,

recent sudden onset]. Patient [denies trauma, admits trauma] to the area. Patient has been treating this

condition with [visits to previous doctors, previous injections, custom made orthotics, NSAIDS, Tylenol, shoe modifications, lifestyle modifications, physical therapy including stretching exercises].


Medications: [Meds]




ROS:


ENMT: [ENMT]



GI: [GI]

GU: [GU]







112




presents wearing [improper shoes, proper shoes, casual shoes, dress shoes, high heels, athletic shoes, sandals, flip flops, crocs].

Dermatological: There [is, is not] warmth appreciated to the effected [medial, plantar, medial and

plantar] foot. [Loss of skin lines of the medial heel is appreciated compared to the contralateral heel.]

There is no evidence of erythema, pitting edema, ecchymosis, nor other signs of trauma to the

heel(s). Adequate fat padding to the inferior aspect of each heel appreciated. Integument [supple, with sign of fungal infection, with signs of pre-ulceration, with signs of bacterial infection].

Vascular: Dorsalis pedis and posterior tibial pulses are [palpable, on-palpable] bilateral. Digital capillary

fill time is <3 seconds bilateral. There are no ischemic skin changes evident bilateral lower extremities.






extremity and foot bilateral. Percussion of the tarsal tunnel and porta pedis [negative, positive] for Tinnel`s or Valieux sign right and [negative, positive] for Tinnel`s or Valieux sign left.

Musculoskeletal: Pain elicited on palpation of the [plantar medial heel, medial heel extending into the

arch, proximal plantar arch, mid-plantar arch, distal medial plantar arch, plantar lateral plantar arch] in

the region of the origin of the intrinsic musculature and plantar fascia, but no pain on medial-lateral

compression of the calcaneus. The medial band of the plantar fascia [ is, is not] tight to palpation with

the toes extended. The Achilles tendon has [full ROM, limited extension with knee locked and unlocked,

limited extension with the knee locked but increased ROM with the knee unlocked]. [There are no other significant foot or ankle deformities bilaterally.]

Radiographs: Weightbearing radiographs 2 views of the [right, left, bilateral] symptomatic foot reveals [a

small developing infra-calcaneal spur/exostosis at the attachment of the flexor digitorum brevis, a large

spur formation at the site of the origin of the extensor digitorum brevis, calcification of the plantar fascia distal to the insertion, no spur formation] and no evidence of tumor, fracture, or cystic changes.

Assessment: Plantar Fasciitis, [Achilles Tendonitis] [right, left, bilateral] with associated Heel Spur

Syndrome/Infracalcaneal Bursitis


versus aggressive therapy including injections of corticosteroid for inflammation relief, radial shock

wave treatments, orthotics, and physical therapy. Further the patient will likely benefit from wearing a

shoe with some arch support like a running shoe, completely refraining from barefoot walking especially

on tile, wood floors, or hard surfaces. Recommend [thin sole orthotic, Aircast® Airheel™, running shoes,

Birkenstock sandals, Orthaheel® flip flops] as assistance for this condition. [Spenco® Thin Sole® orthotic

113

dispensed, Aircast® Airheel™ dispensed, orthofeet prefabricated orthotics dispensed, no assistive device

was dispensed as the patient already wear a device that I find to be proper, patient denies accepting any

assistive shoe devices].

Rx anti-inflammatory options were discussed, including risks of GI ulcer/upset.

Oral and written instructions regarding posterior calf muscle stretching in the morning before arising out

of bed, and after rest, before ambulation to be done at least 5 times daily. [Patient will use ice after activity but not before.]

RTC in [1 week, 2 weeks, 4 weeks] for [next in series of injections, next EPAT treatment, strapping,

follow up] or sooner should problems arise.

Plan: [The patient was injected with a 1:1:1 solution of 0.5% Marcaine™ with Epinephrine and 1%

lidocaine plain and 1 ml of dexamethasone phosphate (4mg/ml),The patient was injected with a 1:1:1

solution of 0.5% Marcaine™ plain and 1% lidocaine plain and 1 ml of Kenalog® (40mg/ml),The patient

was injected with a 1:1:1 solution of 0.5% Marcaine™ plain and 1% lidocaine plain and 1/2 ml of

dexamethasone phosphate (4mg/ml) and 1/2 ml of Kenalog® (40mg/ml),The patient was injected with a

1:1:1 solution of 0.5% Marcaine™ plain and 1% lidocaine plain and 1/2 ml of dexamethasone phosphate

(4mg/ml) and 1/4 ml of Kenalog® (40mg/ml), Ultrasound performed for less than 15 minutes on the

effected heel(s),EPAT treatment was initiated today for 2000 pulses per symptomatic foot at 10 HZ , I

explained this is a relief of symptoms and not a cure, No treatment was initiated today as the patient

elects to be ultra-conservative and rely on the stretching exercises and orthotic therapy for relief before

becoming more aggressive]. The patient [tolerated this well, tolerated the treatment but not well, had a

syncope reaction to the treatment]. [EPAT bar level at end of treatment:] [1.0,1.2,1.4,1.6,1.8,2.0,2.2,2.4,2.6,2.8,3.0]

Figure 40 – Illustration Plantar Fasciitis

114

Plantar Fasciitis - D/C Patient: [Patient.Name] Account No: [Patient.AcctNo] Date: [Date]

Subjective: Patient returns for follow-up evaluation for symptomatic plantar fasciitis. The patient admits[10,20,30,40,50,60,70,80,90,100]% improvement from the initial visit.

Objective: The patient is intact from a neurovascular standpoint with no change since their last visitation bilateral lower extremity.

Musculoskeletal: There is [no, slight, moderate, severe] tenderness on palpation of the plantar medial

calcaneal tubercle in the region of the origin of the plantar fascia and intrinsic musculature, and no pain on medial-lateral compression of the calcaneus.

Assessment: Follow-up plantar fasciitis [right, left, bilateral], heel spur syndrome [improved, worsening, no improvement].

Plan: I have recommended continued use of current treatment and at-home instructions for the next 3

months’ time at which point this condition should fully subside. I explained the symptoms may return in

the future at which time the patient will use the stretching exercises and the insoles to prevent

progression. I will see them back on a PRN basis and have cautioned them to return for a follow -up visit

should problems arise or become exacerbated. All questions answered.

Plantar Fasciitis – Follow-up - Orthotics


Subjective: Patient returns for follow-up evaluation of symptomatic [right, left, bilateral] plantar fasciitis

with heel spur syndrome. The patient [has, has not] been compliant with at-home instructions. The

patient rates the current improvement as [0,10,20,30,40,50,60,70,80,90,100]% improvement. The

patient is considering orthotic therapy.

Objective: The patient is intact from a neurovascular standpoint to the bilateral lower extremities, with no change since the last visit.

Dermatological: There is no edema, erythema, ecchymosis, open lesions, fat pad atrophy or cardinal signs of infection evident at this time bilateral lower extremity.

Musculoskeletal: There is [slight, moderate, severe] tenderness on palpation of the [right, left, bilateral]

plantar medial calcaneal tubercle in the region of the origin of the plantar fascia and intrinsic

musculature, but no pain on medial-lateral compression of the calcaneus. The plantar ligament is [tight, supple, non-palpable].

Assessment: Follow-up [right, left, bilateral] plantar fasciitis, heel spur syndrome with bursitis [without improvement, with some improvement].

Plan: I have recommended continued use of current treatment along with the addition of a custom

orthotic appliance to control the hindfoot and forefoot motion, cushion the heel, and provide for a slight

115

heel lift effect as well. After obtaining appropriate range of motion measurements of the hindfoot to

forefoot relationship which is documented in the orthotic fabrication form, using 4 strips of plaster per

foot, the right and left feet were then casted for negative impressions necessary for fabrication of a

model of the feet to create functional orthotic appliances/foot inserts. These functional foot

orthotics/foot inserts will be packaged, handled, and mailed to an outside laboratory and fashioned as

removable devices with appropriate longitudinal arch support and metatarsal balancing as indicated by the symptomatic deformity. We will see the patient back in [2 weeks, 4 weeks, PRN].

Figure 41 – Example of Insert

Plantar Fasciitis - Follow-up - Steroid Injections Patient: [Patient.Name] Account No: [Patient.AcctNo] Date: [Date]

Subjective: Patient returns for follow-up evaluation of symptomatic [right, left, bilateral] plantar fasciitis.

Patient relates [0, 10, 20, 30, 40, 50, 60, 70, 80, 90, 100] % improvement since the initial visit. [Has, Has

not] been compliant with the at-home treatment and orthotic instructions. The patient [denies

complications arising out of current treatment, admits pain after the injection but resolved in a matter of a day or so, admits local or systemic signs of infection, admits calf pain or tenderness].

Objective: The patient is intact from a neuro-vascular standpoint with no change since the last visit

bilateral lower extremity.

116

Dermatological: There is no erythema, ecchymosis, open lesions, fat pad atrophy nor cardinal signs of

infection evident at this time bilateral lower extremity. The edema around the heel is [improved,

worsened, resolved].

Musculoskeletal: There is [severe, moderate, mild, minor, no] tenderness on palpation of the [right, left,

bilateral] plantar fascia and intrinsic musculature. The plantar ligament is [tight, less tight, supple, non palpable, with palpable defect].

Assessment: Follow-up [right, left, bilateral] plantar fasciitis, heel spur syndrome with bursitis

[improved, no improvement, worsening].

Plan: Encouraged patient to continue at-home physical therapy and orthotic instructions. Based on the

symptoms at this point I recommend [continue current injection regimen, stop injection therapy, casting

for custom orthotics to control the hindfoot and forefoot motion while cushioning the heel and provide

for a slight heel lift effect as well, placing in a BK cast for offloading, referral for neurological evaluation] RTC [1, 2-3, 4, 12] weeks’ time to re-evaluate or sooner should problems arise.

Plan: The symptomatic area was prepped numerous times with an isopropyl alcohol solution. A [1st, 2nd,

3rd] cortico-steroid injection consisting of 1cc of 0.5% Marcaine™ with Epinephrine, 1ml of 1% lidocaine

plain, and [1ml of Dexamethasone phosphate (4mg/ml), 1ml of Kenalog® (40mg/ml, 1/2ml of Kenalog®

(40mg/ml, 1/4ml of Kenalog® (40mg/ml)] was infiltrated in and around the symptomatic area via

[medial, plantar] approach, with good relief obtained. Hemostasis was achieved with compression, the

skin was cleansed, and a dry sterile dressing applied. [Ultrasound was performed for less than 15

minutes at 1 watt over the affected area.] [A low-Dye strap was applied to the affected foot.] The

patient was cautioned regarding hypopigmentation, fat atrophy, rupture of involved ligamentous and tendinous structures, and steroid flare.

Figure 42 – Patient Receiving Plantar Fascia Injection

117

Plantar Fasciitis - Follow-up - Surgery Recommended Patient: [Patient.Name] Account No: [Patient.AcctNo] Date: [Date]

Subjective: Patient returns for follow-up evaluation of symptomatic [right, left, bilateral] plantar fasciitis

with heel spur syndrome. Patient has not been doing very well since the last visit and has been very

compliant with the instructions for home treatment of heel pain. Patient relates current pain as [0/10,

1/10, 2/10, 3/10, 4/10, 5/10, 6/10, 7/10, 8/10, 9/10, 10/10] (10 being the worst) and does not appear to

have responded to our current treatment protocol. The patient denies any fever, chills, nausea or

vomiting, calf pain or tenderness, shortness of breath or chest pain, and local or systemic signs of

infection.

Objective: The patient is intact from a neurovascular standpoint bilateral lower extremities with no change since the last visit.

Dermatological: There is no edema, erythema, ecchymosis, open lesions, fat pad atrophy or cardi nal signs of infection evident in bilateral lower extremities at this time.

Musculoskeletal: There is slight tenderness on palpation of plantar medial calcaneal tubercle in the

region of the origin of the plantar fascia and intrinsic musculature, but no pain on medial -lateral

compression of calcaneus, with a strong posterior tibial tendon to manual resistance, and ankle joint

dorsiflexion of +5 degrees with the knee extended bilateral. Shoe gear and insoles continue to be in

good repair and show no significant wear pattern.

Assessment: Follow-up [right, left, bilateral] plantar fasciitis, heel spur syndrome with bursitis without improvement

Plan: I have recommended continued use of at-home stretching instructions and custom orthotic

appliances which have failed to conservatively treat the patient's significant pain. We discussed

treatment options including use of a night splint or walking cast but patient desired not to use these due

to difficulty of use. We discussed surgical intervention including EPF or ESWT, as well as the risks,

complications, and expected recovery course for these procedures. Patient will consider the options

and schedule accordingly, otherwise patient will continue with the current protocol and we will see

them back in 4 weeks’ time to re-evaluate the situation or sooner should problems arise. Informed

consent [given to take home and discuss with family, signed and in chart and surgery to be scheduled.

Ordered pre-operative clearance by primary doctor. Will schedule procedure after clearance is

obtained.]

118

Figure 43 – Plantar Fasciitis Surgery

Plantar Fibroma Patient: [Patient.Name] Account No: [Patient.AcctNo] Date: [Date]


[right, left, bilateral] arch(s). Patient states the problem has been present for [1mo., 2mos., 3mos.,

4mos., 5mos., 6mos., 1 year, 2 years, over 2 years]. Patient rates pain as [1, 2, 3, 4, 5, 6, 7, 8, 9, and

10]/10, (10 being the worst). Patient admits to [no aggravating activities, exacerbated by walking for

exercise, walking barefoot at home, standing at work, high activity at work, high-impact exercises,

recent sudden onset, aggravated by shoe gear]. Patient [denies trauma, admits trauma] to the area.

Patient has been treating this condition with [benign neglect, visits to previous doctors, previous

injections, custom made orthotics, OTC orthotics, NSAIDS, Tylenol, shoe modifications, lifestyle modifications, physical therapy including stretching exercises].

119


Medications: [Meds]




ROS:


ENMT: [ENMT]



GI: [GI]

GU: [GU]










presents wearing [improper shoes, proper shoes, casual shoes, dress shoes, high heels, athletic shoes,

sandals, flip flops, crocs].

Dermatological: There [is, is not] warmth appreciated to the effected [proximal plantar, middle plantar,

distal plantar] foot. There is a palpable lesion which measures Measurement mm x Measurement mm.

The lesion is [firm, soft, easily movable, non-movable, has pulsatile flow on Doppler, transilluminates

light]. There [is, is not] sign(s) of trauma to the area. Adequate fat padding to the inferior aspect of each

heel appreciated. Integument [inflamed, supple, with sign of fungal infection, with signs of pre-ulceration, with signs of bacterial infection].

120

Vascular: Dorsalis pedis and posterior tibial pulses are [palpable, non-palpable] bilateral. Digital capillary fill time is <5 seconds bilateral. There are no ischemic skin changes evident bilateral lower extremities.


(< 12 mm at level of hallux tuft), vibration (128 MHz tuning fork) and protective threshold (5.07 Semmes

Weinstein monofilament) are intact and without focal motor or sensory deficit bilateral lower

extremities. Normal muscle mass appreciated to both the lower extremity and foot bilateral. Percussion

of the tarsal tunnel and porta pedis [negative, positive] for Tinnel`s or Valieux sign [right, left, bilateral].

Musculoskeletal: Pain [is, is not] elicited on palpation of the lesion. The plantar fascia is [tight with simulated weight-bearing, not tight].

Radiographs: Weightbearing radiographs 2 views of the [right, left, bilateral] symptomatic foot reveals [a

small developing infra-calcaneal spur/exostosis, a large spur, calcification of the plantar fascia distal to

the insertion, no spur formation] but no evidence of tumor, fracture, or cystic changes.

Assessment: Plantar Fibroma [Plantar fasciitis, Achilles Tendonitis] [right, left, bilateral]


versus aggressive therapy including injections of corticosteroid for inflammation relief, radial shock

wave treatments, orthotics to offload the area, and physical therapy. Further the patient will likely

benefit from wearing an athletic shoe that will accommodate the arch support like a running shoe.

Recommend [custom orthotics, thin sole orthotics, orthofeet inserts, Aircast® Airheel™, running shoes,

Birkenstock sandals] as tolerated. Rx options were discussed including GI ulcer risk. Oral and written

instructions regarding posterior calf muscle stretching in the morning before arising out of bed, and

before ambulation to be done at least 5 times daily.

RTC in [1 week, 2-3 weeks, 4 weeks] for [next in series of injections, next EPAT treatment, strapping, follow up] or should problems arise.

Treatment: [The patient was injected with 1 ml of dexamethasone phosphate (4mg/ml),The patient was

injected with 1/4 1 mL of Kenalog® (40mg/ml),ultrasound performed for less than 15 minutes on the

effected heel(s),EPAT treatment was initiated today for 2000 pulses per symptomatic foot at 10 HZ ]. [I

explained this is a relief of symptoms and not a cure, No treatment was initiated today as the patient

elects to be ultra-conservative and rely on the stretching exercises and orthotic therapy for relief before

becoming more aggressive]. [EPAT bar level at end of treatment:][1.0,1.2,1.4,1.6,1.8,2.0,2.2,2.4,2.6,2.8,3.0]

121

Figure 44 – Patient Presenting with Plantar Fibroma

Figure 45 – Illustration about Plantar Fibroma

122

Posterior Tibial Tendonitis - Initial Visit Patient: [Patient.Name] Account No: [Patient.AcctNo] Date: [Date]

Chief Complaint: Patient is a [Age] year old [Sex] who presents today with complaint of a painful [ right,

left] foot and ankle which has been present for [days, weeks, months, years]. Patient [has, has not]

experienced recent trauma. The pain is [improving, worsening, unchanged] since onset. Patient has

been treating this condition with [NSAIDS, shoe modifications, immobilization and non-weight-bearing]. Patient [has, has not] noticed a significant mal-position.


Medications: [Meds]




ROS:


ENMT: [ENMT]



GI: [GI]

GU: [GU]








123



Edema is graded as [0, +1, +2, +3]. No varicosities, telangiectasias, pigmented lesions or signs of venous

stasis changes bilateral lower extremities. Adequate fat padding to the inferior aspect of the feet. Skin is normal color and turgor otherwise.


capillary fill time is <5 seconds bilateral. There are no ischemic skin changes evident bilateral lower extremities.








Musculoskeletal: Pain elicited on palpation of the posterior tibial tendon complex in the [watershed

area, insertion into the navicular, above the level of the malleolus]. It has [no palpable abnormality,

fusiform swelling, palpable defect in the tendon substance]. Strength of the tendon in pronation against

resistance is graded as [0, 1, 2, 3, 4, 5]/5. Intact flexor hallucis longus tendon, strength graded at [0, 1, 2,

3, 4, 5]/5. Ankle joint ROM is [normal, limited, worsening, improving] with the knee extended [bilateral,

right, left]. Contractures and joint subluxation on weight bearing of the [toes, mid-tarsal joint, Chopart's

joint] [right, left, bilateral]. Patient [able, unable] to perform heel raise on the [right, left, bilateral]. Heel is [everted, extremely everted, rectus, collapsed and patient is walking on the tibia].

Radiographs: Weightbearing radiographs [1,2,3] views of the symptomatic foot reveal [no gross boney

abnormalities, uncovering of the talus on the navicular, low calcaneal inclination angle, obliteration of the sub-talar joint, a halo sign].

Assessment: Posterior tibial tendonitis [right, left, bilateral]


conservative versus aggressive therapy. Will [mobilize, immobilize] the tendon with [PTTD pneumatic

brace, Airheel™, Aircast® walker, fiberglass cast, orthotic device, modified Jones cast, Soft paste cast,

ankle stirrup] completely refraining from unassisted walking. While symptomatic use of an ice pack

twice a day for 10-15 minutes. Rx options were discussed, patient cautioned regarding GI ulcer risk.

Recommend wear the device every day as the structure of the foot allows. Oral and written instructions given regarding compliance. RTC in [1, 2, 3, 4, 6, 12] weeks.

Steroid Injection

124

Figure 46 – Illustration of Posterior Tibial Tendonitis

Posterior Tibial Tendonitis - Follow-up Patient: [Patient.Name] Account No: [Patient.AcctNo] Date: [Date]

Chief Complaint: Patient presents today for follow up of a painful posterior tibial tendonitis of the [right,

left, bilateral] foot. Patient [has, has not] been compliant with changes in activities and wearing

assistive devices. The pain is [improving, worsening, unchanged] since last visit. Admits

[0,10,20,30,40,50,60,70,80,90,100]% relief. Patient has been treating this condition with [NSAIDS, shoe modifications, immobilization and non-weight-bearing].

125

Examination: The patient is appropriately dressed, articulate, awake, alert, and oriented x 3, appears their stated age and appears to be in good health.


Edema is graded as [0, +1, +2, +3]. No varicosities, telangiectasias, pigmented lesions or signs of venous

stasis changes bilateral lower extremities. Adequate fat padding to the inferior aspect of the feet. Skin is normal color and turgor otherwise.


capillary fill time is <5 seconds bilateral. There are no ischemic skin changes evident bilateral lower extremities.








Musculoskeletal: [No change in, Improvement in, Worsening] pain elicited on palpation of the posterior

tibial tendon complex in the [watershed area, insertion into the navicular, above the level of the

malleolus]. Strength of the tendon in pronation against resistance is graded as [0, 1, 2, 3, 4, 5]/5. Intact

flexor hallucis longus tendon, strength graded at [0, 1, 2, 3, 4, 5]/5. Ankle joint ROM is [normal, limited,

worsening, improving] with the knee extended [bilateral, right, left]. Contractures and joint subluxation

on weight bearing of the [toes, mid-tarsal joint, Chopart's joint] [right, left, bilateral]. Patient [able,

unable] to perform heel raise on the [right, left, bilateral]. Heel is [everted, extremely everted, rectus, collapsed and patient is walking on the tibia].

Radiographs: Weightbearing radiographs 2 views of the symptomatic foot reveal [no gross boney

abnormalities, uncovering of the talus on the navicular, low calcaneal inclination angle, obliteration of the sub-talar joint, a halo sign].

Assessment: Posterior tibial tendonitis [right, left, bilateral] [improving, unchanged, worsening]


conservative versus aggressive therapy. Will [mobilize, immobilize] the tendon with [PTTD pneumatic

brace, Airheel™, Aircast® walker, fiberglass cast, orthotic device, modified Jones cast, Soft paste cast,

ankle stirrup] completely refraining from unassisted walking. While symptomatic use of an ice pack

twice a day for 10-15 minutes. Rx options were discussed, patient cautioned regarding GI ulcer risk.

Recommend wear the device every day as the structure of the foot allows. Oral and written instructions given regarding compliance. RTC in [1, 2, 3, 4, 6, 12] weeks.

Steroid Injection

126

Sesamoiditis – Initial Visit Patient: [Patient.Name] Account No: [Patient.AcctNo] Date: [Date]

Subjective: This year-old presents to the office with a chief complaint of pain in [right, left, bilateral]

plantar great toe joint area which has been present for several [days, weeks, months, years]. Patient

complains of [sharp pain, throbbing, aching, shooting pains, burning pain] below big toe joint. The

symptoms increase with walking and standing, [is, is not] present with all types of shoes and symptoms

increases with pressure is applied below big toe joint. Previous treatment includes: [rest, ice, anti-

inflammatories, strapping, padding, OTC orthotics, modification of activity, previous doctor visits].

Patient [denies, reports] [recent, previous] trauma to the area.

Allergies: No known medical allergies.

Immunizations: Patient is up-to-date on immunizations and has received a tetanus shot within the last 10 years.

Medications: Patient denies taking any prescription medications or OTC remedies at this time.




Review of Systems:


Eyes: [Eyes]





Genitourinary: [GU]




Psychiatric: Psychiatric]

127




Physical Examination: Patient is well developed and oriented x3 with good attention to grooming and body habitus. [Vitals].

Vascular: Dorsalis pedis pulses are [NP,1,2,3,4]/4 right, [NP,1,2,3,4]/4 left. Posterior tibial pulses are

[NP,1,2,3,4]/4 right, [NP,1,2,3,4]/4 left. Capillary filling time with the leg elevated is [normal*,

immediate, delayed] at the level of the digital tufts bilaterally. There [are, are no] ischemic skin changes

evident in [the right, the left, either] lower extremities. There [is, is no] edema noted in the lower

extremities. Digital hair [present, normal, reduced, absent, ample]. Temperature at the toes is [cold, cool, tepid, warm, hot].



monofilament) are intact and without focal motor or sensory deficit bilateral lower extremities. Normal

muscle mass appreciated to both the lower extremity and foot bilateral. Negative Mulder`s sign to the interspaces of both feet.

Dermatological: Color, texture, and turgor are within normal limits bilateral lower extremities. There [ is,

is no] erythema overlying the dorsomedial eminence of the [left, right, bilateral] 1st MTPJ. There [is, is

no] [erythema, hyperkeratosis, local heat, signs of skin stress, skin breakdown, pre-ulceration, ulceration, evidence of infection] beneath the [right, left] [tibial, fibular] sesamoid.

Musculoskeletal: One notes a [pronated, neutral, cavus] foot type with [no, mild, moderate, severe]

gastro-soleus equinus deformity [left foot, right foot, of both feet]. A limb length discrepancy is noted

with the [right, left] noted to be the long limb. Range of motion of the ankle, subtalar and midtarsal

joints [are, are not] painfree and within normal limits. Crepitus [is, is not] noted. There [are, are no] digital contractures noted. Muscle strength is [1, 2, 3, 4, 5]/5 for all four lower extremity muscle groups.

Sesamoid Examination: There is pain to palpation of the [right, left]] [fibular, tibial] sesamoid bone.

There [is, is no] pain to palpation of the tibial sesamoid-metatarsal articulation medially. There [is, is no]

hypertrophy of the sesamoid bone noted. There [ is, is no] crepitus upon range of motion. There is [pain,

no pain] on 1st MTPJ range of motion. Localized redness and swelling is [noted, not noted] on the

plantar aspect of the first metatarsophalangeal joint of the [right, left] foot. There [is, is no] clinical evidence of fracture or dislocation noted.

Radiographic Evaluation:

Views: [2, 3] weightbearing views of [the right, the left, both feet] were obtained. These views were [AP, Lat, LO, MO, SA].

Soft Tissue Density: [normal, edema noted, lesions noted]

128

Bone/Joint Quality/Density: [WNL, appears demineralized, degenerative changes noted]. The [right, left,

bilateral] [fibular, tibial] sesamoid bone is [bipartite, multipartite, enlarged, diminutive, degenerative,

deformed, displaced, fractured].

Fracture: [None, Non-displaced, Displaced, Comminuted, Transverse, Spiral]

Alignment/Deformities: [Normal, Pronated, Supinated, Cavus, Calcaneal valgus, Bullet hole sign, Halo sign, HAV, Met-adductus, Skew foot, Digital contractures noted].

Radiographic Impression: Reveals a

[hypertrophic,displaced,deviated,subluxed,degenerative,fractured,atrophic][right,left,bilateral][fibular,ti

bial] sesamoid bone.

Assessment:

1) [729.5]

2) [733.99]

3) [727.3]

Plan:

I discussed the pathology and the treatment options for sesamoiditis. We discussed non-surgical

conservative treatment options and surgical treatment of the condition. I recommended to the patient

in this case that we proceed with [non-surgical measures to treat the, surgical treatment of the] condition.

I recommended wearing supportive shoes at all times such as a well-constructed athletic shoe and to

limit wearing flimsy shoes such as a sandals, flip-flops, or slippers. I advised the patient avoid barefoot walking, sock-footed, or slippers in the house for long periods of time especially on hard floors.

I discussed arch supports and how such a device will help to control pronation and reduce pressure to

the sesamoid area. I discussed both prefabricated arch supports and custom-made orthotics. I

explained the benefits from each of these two options. The patient wishes to proceed with

prefabricated orthotics and padding as a first-line treatment option and accepts that custom devices

may be needed if this fails to adequately reduce pressure to the area. A pair of Spenco® Thin Sole®

devices was dispensed, size [6, 7, 8, 9, 10, 11, 12, 13]. The sesamoid area [was, was not] further modified to offload the area at this time but may require additional adjustment.

I also recommended a cortisone injection to help reduce the inflammation associated with this condition. The patient elected to [receive, defer] the injection at this time.

RTC in [1 week,2 weeks,3 weeks,1 month] for follow-up.

129

Figure 47 – MRI of Sesamoiditis

Sinus Tarsitis – New Patient Patient: [Patient.Name] Account No: [Patient.AcctNo] Date: [Date]


painful [right, left] [foot, ankle] which has been present for [days, weeks, months, years]. Patient [has,

has not] experienced recent trauma. Patient [has, has not] noticed a malposition of the feet. Patient

rates pain as [1,2,3,4,5,6,7,8,9,10]/10, (10 being the worst). Patient has been treating this condition with [NSAIDS, pain killers, shoe modifications, immobilization and non-weight-bearing, bracing].


Medications: [Meds]




130

ROS:


ENMT: [ENMT]



GI: [GI]

GU: [GU]









Dermatological: There is [ecchymosis, erythema, edema, heat, pain to palpation] of the affected

area. No varicosities, telangiectasias, pigmented lesions or signs of venous stasis changes bilateral lower

extremities. [Adequate, In-adequate] fat padding to the inferior aspect of the feet. Skin is normal color and turgor otherwise.

Vascular: Dorsalis pedis and posterior tibial pulses are palpated at [1, 2, 3, 4]/4 bilateral. Digital capillary

fill time is [immediate, delayed] bilateral. There are no ischemic skin changes evident bilateral lower

extremities.







arise from a seated position unassisted. Percussion of the tarsal tunnel, saphenous nerve distribution and porta pedis [negative, positive] for Tinnel`s or Valieux sign [right, left, bilateral].

Musculoskeletal: Pain elicited on palpation of the [sinus tarsi, joints of the midfoot, joints of the

forefoot, ankle, STJ, MTJ, M-C joints, 1st MPJ, 2nd MPJ, 3rd MPJ, 4th MPJ, 5th MPJ]. There [is, is not] pain

131

and [full ROM, limited ROM] of the sub talar joint compared to the contralateral side. The Achilles

tendon [has no palpable abnormality, has limited rom with knees straight and flexed, fusiform swelling

in the watershed area]. Posterior tibial tendon, strength graded at [1, 2, 3, 4, 5]/5 and [with, without]

pain. Knee appear [rectus, internally rotated, externally rotated]. There [are, are not] other significant foot and/or ankle deformities [right, left, bilaterally].

Radiographs: Weightbearing radiographs [2,3] views of the symptomatic foot reveal [obliteration of the

sinus tarsi, joint space loss, sub-chondral eburnation, cyst formation, osteophytosis, subluxation,

uncovering of the talus on the navicular, misalignment, malalignment, fibrous ankylosis, intra-articular

bodies, low calcaneal inclination angle, normal calcaneal inclination angle, metadductus, no gross boney

abnormalities] of the [1st, 2nd, 3rd, 4th, 5th] [sinus tarsi, PIPJ, MPJ, midfoot, M-C joint, N-C joint, STJ, T-N joint, ankle joint medially, ankle joint laterally].

Assessment: Sinus tarsitis [right, left]


conservative versus aggressive therapy. Will [immobilize, mobilize] the part with [Aircast® walker,

fiberglass cast, modified Jones cast, Soft paste cast, ankle stirrup, orthotics, soft tennis shoes]

completely refraining from unassisted walking. Recommend [cessation of activity especially on uneven

surfaces or beach sand, wear supportive shoes and recommendations were made for this, injection

therapy for pain and inflammation relief, Aircast® bracing, custom orthotics, surgical correction]. Oral

and written instructions given regarding compliance and prognosis.

RTC in [1, 2, 3, 4, 6, 12, prn] weeks.

Figure 48 – X-Ray of Sinus Tarsitis

132

Tailor's Bunionette Deformity Patient: [Patient.Name] Account No: [Patient.AcctNo] Date: [Date]


deformity to the [right, left, bilateral] 5th toe region with pain associated with closed toed shoe gear and

has not responded to [self-care, soaks, lotions, attempted self-debridement, OTC padding, OTC

treatments, shoe gear changes]. Patient has not had a similar condition previously and denies any

recent trauma or inciting events. The patient [does, does not] have a family history of a bunion or other foot deformity.


Medications: [Meds]




ROS:


ENMT: [ENMT]



GI: [GI]

GU: [GU]








133


Vascular: Dorsalis pedis and posterior tibial pulses are readily palpable and graded at 2/4 bilateral.

Capillary filling time with the leg elevated is <5 seconds at the level of the digital tufts bilateral. There are no ischemic skin changes evident bilateral lower extremities.

Musculoskeletal: There is pain on palpation of the great toe which is contracted in a semi-rigid nature at

the 5th MTPJ level with/without track bound phenomenon evident. There are no other significant foot

or ankle deformities appreciated bilateral.





are down going toes and a negative clonus bilateral. Normal muscle mass appreciated to both the lower extremity and foot bilateral. There is pain on palpation of the great toe in the region of the deformity.

Dermatological: There is no evidence of edema, erythema, ecchymosis, open lesions, interdigital


telangectasias, pigmented lesions or signs of venous stasis changes bilateral lower extremities. Adequate fat padding to the inferior aspect of each foot appreciated.

Radiographs: Weightbearing radiographs of the symptomatic foot with comparison views of the

contralateral foot reveal a Tailor's Bunionette deformity with an increased intermetatarsal 4-5 angle,

enlargement of the 5th metatarsal head, and medial angulation of the 5th toe but no evidence of tumor, fracture, or cystic changes.

Impression: Symptomatic Tailor's Bunionette deformity.

Treatment: I have discussed the treatment options with the patient and have dispensed some toe

strapping/silicone padding which they will reapply on a daily basis, recommended use of Vaseline or

similar product to decrease friction, and instructed them to purchase wider shoe gear as well as have

their current shoe gear stretched to accommodate their deformities. Should these measures fail and

their symptoms warrant, I recommended surgical intervention in the form of a metatarsal osteotomy to

correct the deformity present and re-align the MTPJ. I discussed the risks, complications, and expected recovery course in detail. We will see them back on a PRN basis or sooner should problems arise.

_____________________________

[User.Name], [User.Title]

134

Figure 49 – Patient with Bunion and Tailor’s Bunion

Tarsal Tunnel Syndrome - Initial Visit Patient: [Patient.Name] Account No: [Patient.AcctNo] Date: [Date]

Chief Complaint: This [Patient.Age] year old [Patient.Gender] presents today with complaint of a [right,

left, bilateral] [burning, tingling, pins and needles, numb] feeling in the [feet, ball of the foot, heel(s), top

of the foot, up the leg(s), entire foot]. Condition [is painful, is not painful, keeps awake at night, is worse

while in bed]. Patient [admits, denies] any recent trauma or inciting events causing this problem.

Previously treated with [shoe modifications, orthotics, injection therapy, oral medication]. Patient

[admits, denies] lower back pain.


Medications: [Meds]


135



ROS:


ENMT: [ENMT]



GI: [GI]

GU: [GU]









Vascular: Dorsalis pedis and posterior tibial pulses are [palpable, non-palpable] bilateral. Capillary filling

time with the leg elevated is [<5, 5, >5] seconds at the level of the digital tufts bilaterally. The skin

temperature is [warm to warm, warm to cool, warm to cold] from the tibial tuberosity to the toes.

Musculoskeletal: The structure of the foot appears [rectus, supinated, pronated]. There [is, is not] pain

on palpation of the medial ankle [above, below, at] the malleolar level. There [is, is not] pain of the

medial heel at Baxter's nerve. The digits show [normal alignment, spreading of the 2nd and 3rd,

spreading of the 3rd and 4th,, contracture of] digits [of the right foot, left foot, bilateral]. There is

[adequate, weak] muscle strength to manual examination [unilaterally, bilaterally]. [There is no pain with straight leg raise.]

Neurological: Deep tendon reflexes including Achilles and Patellar are [absent, normal, hyperreflexic]

[right, left, bilateral]. Epicritic sensation measuring light touch with Semmes Weinstein monofilament is

graded as [intact, diminished] in [1,2,3,4,5,6,7,8,9,10] /10 places on the digits, forefoot, arch, heel, and

dorsum. Vibratory sensation measured with a 128Hx tuning fork is graded as [intact, diminished,

136

absent]. Normal, atrophic, hypertrophic] muscle mass appreciated to both the lower extremity and foot

bilaterally. Percussion of the [lower extremity nerves is unremarkable, tibial nerve elicits parasthesias of

the medial ankle, common peroneal nerve at the fibular head elicits parasthesias, sural nerve elicits parasthesias, deep peroneal nerve at the dorsum of the foot elicits parastheias].

Dermatological: Skin turgor is [supple, atrophic, thin and shiny, cool, dry, moist, excessively perspiring].

Radiographs: Weightbearing radiographs reveal [digital contractures, no osseous pathology, splaying of the digits, tumor, fracture, cystic changes, crowding of the metatarsal heads].

Impression: [Neuropathy, Tarsal Tunnel Syndrome, Baxter's neuritis, plantar fasciitis, Radiculopathy]

[right, left, bilateral]

Treatment: I have discussed the condition and the conservative treatment options with the patient. At

this point I have recommended [further diagnostic testing, epidermal nerve fiber density biopsy, EMG

and NCV testing, chiropractic evaluation, radiographic limb length study, shoegear modifications, oral

therapy, topical therapy]. I discussed more aggressive treatment options including [corticosteroid

injection therapy, sclerosing therapy, surgical nerve release]. I discussed the risks, complications, and

expected recovery course in detail. The plan at this point is to [live with the numbness and delay

treatments at this time, proceed with further testing, biopsy the skin for epidermal nerve density, start

oral therapy, continue oral therapy, stop oral therapy, topical therapy, referral to chiropractic specialist, referral to orthopedic specialist, referral for NCV EMG testing, referral to peripheral nerve specialist].

RTC in [2 weeks, 3 weeks, 4 weeks, 12 weeks, PRN].

Figure 50 – Illustration of Tarsal Tunnel Syndrome

137

Tarsal Tunnel Syndrome – Established Patient Patient: [Patient.Name] Account No: [Patient.AcctNo] Date: [Date]

Chief Complaint: This [Patient.Age] year old [Patient.Gender] presents today for follow-up. Relates

[improved, unchanged, worsening] symptoms. Improved by [0,10,20,30,40,50,60,70,80,90,100]% improved. [Desires, Does not desire] to continue this line of treatment.

Examination: The patient appears well oriented with good attention to body habitus. The patient is in

[good, fair, poor, at risk] health.


time with the leg elevated is [<5, 5,>5] seconds at the level of the digital tufts bilaterally. The skin

temperature is [warm to warm, warm to cool, warm to cold] from the tibial tuberosity to the toes. There

are no ischemic skin changes evident in bilateral lower extremities.

Musculoskeletal: There [is, is not] pain on palpation of the medial ankle [above, below, at] the malleolar level. There [is, is not] pain of the medial heel at Baxter's nerve.

Neurological: There is [no symptoms, pain, parasthesias] and recreation of symptoms with percussion of

the tibial nerve of the medial ankle [above, below, at] the malleolar level [right, left, bilateral].

Parasthesias also noted to percussion of the [fibular head, anterior ankle].

Dermatological: There are no hyperkeratotic lesions, verruca type tissue, retained foreign bodies, or

cardinal signs of infection. Otherwise, there is no evidence of edema, erythema, ecchymosis, open

lesions, interdigital maceration or signs of bacterial or fungal infection bilateral lower extremities. No

varicosities, telangectasias, pigmented lesions or signs of venous stasis changes in bilateral lower extremities. Adequate fat padding to the inferior aspect of each foot appreciated.

Impression: [Tarsal Tunnel Syndrome, Baxter's neuritis, plantar fasciitis, neuropathy] [right, left]

Treatment: I have discussed the conservative treatment options with the patie nt and recommended

shoegear modifications and orthotics. I discussed more aggressive treatment options including

corticosteroid injection therapy, sclerosing therapy and surgical nerve release. I discussed the risks, complications, and expected recovery course in detail.

Due to the level of pain I have also recommended a corticosteroid injection. I explained this is only a

relief of symptoms and not a cure for the condition. The symptomatic area was prepped numerous

times with alcohol after which a [1st, 2nd, 3rd] corticosteroid injection, consisting of [1 cc of

Dexamethasone phosphate 4mg/ml, 0.5 cc of Dexamethasone phosphate 4mg/ml, 0.5 cc of

Triamcinolone Acetonide 40mg/ml, 1 cc Triamcinolone acetonide 10 mg/ml. 0.25cc of Triamcinolone

Acetonide 40mg/ml] was infiltrated in and around the symptomatic area with good relief

obtained. Hemostasis was achieved with compression, the skin was cleansed, and a dry sterile dressing

applied. The patient tolerated this well and was cautioned regarding hypopigmentation, fat atrophy, rupture of involved ligamentous and tendinous structures, and steroid flare.

138

This patient will return to the clinic in [2 weeks, 3 weeks, 4 weeks, 12 weeks, prn].

Tinea Pedis - Initial Visit Patient: [Patient.Name] Account No: [Patient.AcctNo] Date: [Date]

Chief Complaint: This [Patient.Age] year old [Patient.Gender] presents today with complaint of [itching,

peeling, flaking, dry, moist, burning, red] skin. Problem has been present for several [weeks, months,

years]. Patient [admits, denies] any other rashes on the body. Patient denies a family history of this

condition and [has, has not] had a similar problem in the past. Last seen by PCP,

[Patient.PrimaryPhysician] on [Patient.DateLastSeen].


Medications: [Meds]




ROS:


ENMT: [ENMT]



GI: [GI]

GU: [GU]







139




the leg elevated is [<5, 5,>5] seconds at the level of the digital tufts bilaterally. There are no ischemic skin changes evident bilateral lower extremities.

Musculoskeletal: Normal strength, range of motion and alignment for all joints from the ankle distal evident bilateral.





are down going toes and a negative clonus bilateral. Normal muscle mass appreciated to both the lower extremity and foot bilateral.

Dermatological: There is a [erythematous, scaly, macerated, peeling, dry, vesicular] rash appearance to

the [plantar, interdigital, dorsal] aspect of [right, left, bilateral] foot. [The appearance is in a moccasin

distribution.] This lesion [does, does not] glow under woods light. Otherwise, there is no evidence of

edema, ecchymosis, open lesions, signs of bacterial infection of bilateral lower extremities. No

varicosities, telangectasias, pigmented lesions or signs of venous stasis changes to bilateral lower extremities. Adequate fat padding to the inferior aspect of each foot appreciated.

Impression: Symptomatic tinea [pedis, corporis, capitus, interdigitus]

Treatment: I have discussed the treatment options with the patient and have recommended use

household Lysol in the shoes to eradicate the fungal infection. Recommend washing all products that

come in contact with feet in household bleach to remove the source of the fungus (bed sheets, socks,

bath carpets, towels, etc.). I have discussed topical versus oral treatments and the typical risks and

complications of these approaches. We will see them back in 4 weeks’ time or sooner should problems arise.

140

Figure 51 – Patient with Tinea Pedis

Tinea Pedis - Follow-up Patient: [Patient.Name] Account No: [Patient.AcctNo] Date: [Date]

Subjective: Patient returns [2,3,4,5,6,7,8] weeks since last visit for follow-up evaluation of symptomatic

tinea pedis for which I dispensed [NAFTIN gel, NAFTIN cream, Loprox® gel] and recommended applying

[QD, BID]. Patient [has, has not] been using Lysol spray QD to shoe gear, cleaning all clothes that contact their feet, and exercising proper foot hygiene. Patient feels the problem is [ improving, worsening].

Objective: Dermatological: Both feet have [improvement, worsening, resolution] of the fungal infection.

Assessment: Follow-up tinea pedis [improved, unchanged, worsened, resolved].

Treatment: I have recommended completing the topical anti-fungal course for the next few weeks to

finalize treatment. I will see them back on a PRN basis and have cautioned them regarding recurrence

and proper attention to immediate treatment.

141

Neurology Neuroma - Initial Visit Patient: [Patient.Name] Account No: [Patient.AcctNo] Date: [Date]

Chief Complaint: This [Patient.Age] year old [Patient.Gender] presents today with complaint of a

[burning, sharp, dull, numb, tingling, constant, intermittent] pain in the [ball of the foot, 2nd and 3rd toes,

3rd and 4th toes, foot running up the leg] that is associated with weight bearing and came on [suddenly,

gradually]. This is present [in closed toed shoe gear, barefooted and with shoes, dress shoes]. Treatment

to this point has included [consultation and treatment by other doctors, injection therapy, orthotic

therapy, oral anti-inflammatories, soaks, OTC padding, shoe gear changes, soaks]. Patient [has, has not]

had a similar condition previously and [admits, denies] any recent trauma or inciting events. Problem seems to be [worsening, constant and unchanging, improving, exacerbating and remitting].


Medications: [Meds]




ROS:


ENMT: [ENMT]


Respiratory:[Respiratory]

GI: [GI]

GU: [GU]






142



Examination: The patient is [appropriately dressed, articulate, awake, alert, and oriented x 3, appears to be in good health, is overweight, in poor health]. Their vitals are as follows: [Vitals].


time with the leg elevated is [<3, 3, >3] seconds at the level of the digital tufts bilaterally. The skin

temperature is [warm to warm, cool to cool, warm to cool, warm to cold] from the tibial tuberosity to the toes. There are no ischemic skin changes evident in bilateral lower extremities.

Musculoskeletal: There [is, is not] pain on palpation of the lesser metatarsal heads [2, 3, 4, 5]. The digits

show [normal alignment, spreading of the 2nd and 3rd, spreading of the 3rd and 4th] [of the right foot,

left foot, bilateral]. There are no other significant foot or ankle deformities appreciated, and [adequate, weak] muscle strength to manual examination bilaterally.

Neurological: [Deep tendon reflexes including Achilles and Patellar are normal, brisk, and symmetrical


mm at level of hallux tuft), vibration (128 MHz tuning fork) and protective threshold (measured with a

Semmes Weinstein monofilament) are intact and without focal motor or sensory deficit in bilateral

lower extremities]. There is pain and recreation of symptoms with Mulder`s test and palpation of the

[right, left, bilateral] [first, second, third, fourth] interdigital space. Palpable click [is, is not] present.

Dermatological: Skin in the area of concern [showing edema in the innerspace, showing erythema of the plantar tissue near the innerspace, showing no obvious signs].

Radiographs: Weightbearing radiographs [2, 3] views of the symptomatic foot reveal [no osseous

pathology, tumor, fracture, cystic changes, crowding of the metatarsal heads]. There [is, is not] splaying

of the lesser toes to the symptomatic web space(s).

Impression: [Morton's neuroma, 2nd space interdigital neuroma, 4th space interdigital neuroma, metatarsalgia] [right, left]

Plan: I have discussed the conservative and aggressive treatment options with the patient. I have

discussed and recommended shoes with a wide toe box and discussed which shoes to stay away from. I

have discussed conservative treatment options to include: [metatarsal padding, custom orthotics,

lifestyle changes]. I discussed more aggressive treatment options including: [corticosteroid injection

therapy, sclerosing therapy, cryosurgery, surgical nerve excision. I discussed the risks, complications, and

expected recovery course in detail. At this point the patient desires to [be conservative and try padding

the area, change shoe style, be casted for custom orthotics, start cortisone injections, have the nerve sclerosed, have cryosurgery, have the nerve removed].

RTC in [11-14 days, 4 weeks, 12 weeks, prn].

143

Neuroma - Follow-up - Steroid injection Patient: [Patient.Name] Account No: [Patient.AcctNo] Date: [Date]


2nd, 3rd, 4th] interspace. Treatment at this point has consisted of [padding, strapping, icing, orthotics,

activity restriction, shoegear changes, anti-inflammatory injections, NSAIDS, pain meds]. Patient states

[much improved, no change in symptoms, felt improved for a few days but now back to hurting, feels

somewhat improved, able to move toes freely once again, able to wear shoes without pain, able to

walk/run again, feels like the foot is not as stiff, injection made it hurt for a few days after]. States

overall improvement at this point is [0%,10%,20%,30%,40%,50%,60%,70%,80%,90%,100%,continued].

Patient [desires to continue this line of treatment, desires to change her treatment plan, desires to stop

treatment, elects to move to more aggressive techniques or surgical procedures as significant

improvement has not been achieved, desires to exercise benign neglect and monitor for worsening symptoms].



Meds: [Meds]

PMH: [PMH]

PSH: [PSH]

PFH: [PFH]


ROS:


ENMT: [ENMT]

CV: [CV]


GI: [GI]

GU: [GU]





MSK: [MSK]

144




Musculoskeletal: There is [no pain, pain] on palpation of the lesser metatarsal heads.

Neurological: There is [significant, moderate, mild, minor] pain and recreation of symptoms with Mulder`s test and palpation of the [right, left] [1st, 2nd, 3rd, 4th] inter-digital space.

Assessment: Symptomatic [Morton’s, interdigital] neuroma, [right, left] [1st, 2nd, 3rd, 4th] interspace

[improving, unimproved, worsening].


padding and proper shoe gear as we discussed at last visit. I have recommended a [1st, 2nd, 3rd, 4th]

[corticosteroid injection, alcohol sclerosing injection as patient has failed both mechanical and

pharmacologic treatments] to resolve the symptoms further. I discussed shoe gear and the need to stay

out of tight shoes especially with a pointed toe box. I discussed correct placement of padding and I

recommend use regularly. If these measures fail and the symptoms persist I would recommend [the

patient to make lifestyle adjustments to accommodate symptoms, custom made orthoses, sclerosing

therapy, surgical excision, cryotherapy].

RTC [11-14 days, 4 weeks, 12weeks, PRN].

Neuroma - Follow-up - Surgery Recommended Patient: [Patient.Name] Account No: [Patient.AcctNo] Date: [Date]

Subjective: Patient presents today for follow-up evaluation of symptomatic Morton`s neuroma which we

have treated conservatively with ice, wider shoes, massage, limited weight bearing activities, oral anti-

inflammatory, and corticosteroid injection. They have not noticed any significant relief of their symptoms with these measures.

PMH, PSH, Meds: Reviewed in detail and unchanged since last examination.

Objective: Unchanged vascular and dermatological status of bilateral lower extremity.

Musculoskeletal: There continues to be no pain on palpation of the lesser metatarsal heads or MTPJ

plantar plates with stable digital exams evident with modified Lachman stressing. There are no other

significant foot or ankle deformities appreciated, stable foot posture, and adequate muscle strength to manual examination bilaterally.

Neurological: There is significant pain and recreation of symptoms with Mulder`s test and palpation of

the [right, left] [first, second, third, fourth] inter-digital space. Medial-lateral compression of the

interdigital space and deep palpation of the interspace also reproduces symptoms.

145

Assessment: Symptomatic neuroma [right, left] [1st, 2nd, 3rd, 4th] interspace, unimproved.


conservative measures we discussed at their last visitation. Since the injections provided in past visits

have failed to provide any long-term symptomatic relief, we discussed surgical intervention. They

understand that nerve surgery carries the risk of permanent anesthesia or dysesthesias and a stump

neuroma can occur as well. They have been advised of the approximate disabili ty involved for these

procedures. In addition, the patient has been advised as to the alternatives of care, including continued

conservative care. The patient understands that if surgical procedures are performed, there are risks

and complications that could occur, including but not limited to: hematoma formation, seroma

formation, development of a DVT or phlebitis, infection, painful scar tissue formation, limited motion,

and recurrence with continued pain, and the possibility that future surgery may need to be performed.

An informed consent was given to the patient [to take home and discuss with the family, signed and

placed in the chart]. The patient was given the opportunity to ask questions which were answered to the

best of my ability. The patient voiced no concerns and will consider all these options and schedule

accordingly. This patient [will obtain medical clearance from primary care doctor, will be scheduled for surgery based on pre-operative physical performed today].

Return to clinic as needed.

Figure 52 – Surgery of Neuroma

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Neuroma Discharge Patient: [Patient.Name] Account No: [Patient.AcctNo] Date: [Date]

Subjective: Patient was seen today for follow-up of symptomatic Morton`s neuroma [right, left,

bilateral] foot. Patient has used [wider shoe gear, ice, limited weight bearing activities, massage to the

area, oral anti-inflammatories, metatarsal padding] with good relief obtained. The symptoms are much

less intense and no longer interfere with daily activities.


Objective: Vascular and dermatological status is unchanged since last visit for bilateral lower extremities.

Musculoskeletal: There continues to be no pain on palpation of the lesser metatarsal heads or MTPJ plantar plates with stable digital exams evident with modified Lachman stressing.

Neurological: Palpation of the [1st, 2nd, 3rd, 4th] [right, left] inter-digital space reveals [positive

Mulder's sign with pain, positive Mulder's sign without pain, no symptoms].

Assessment: Neuroma, [right, left] [1st, 2nd, 3rd, 4th] interspace, resolved with conservative treatment.

Plan: I have recommended [continued use of the conservative measures, further steroid injection, ETOH injections, discharge for now]. We will see patient back on a PRN basis or sooner should problems arise.

Neuropathy


Chief Complaint: This [Patient.Age] year old [Patient.Gender] presents today with complaint of a [right,

left, bilateral] [burning, tingling, pins and needles, numb] feeling in the [feet, ball of the foot, heel(s), top

of the foot, up the leg(s), entire foot]. Condition [is painful, is not painful, keeps awake at night, is worse

while in bed]. Patient [admits, denies] any recent trauma or inciting events causing this problem.

Previously treated with [shoe modifications, orthotics, injection therapy, oral medication, spinal injections, antidepressant meds]. Patient [admits, denies] lower back pain.


Medications: [Meds]




147

ROS:


ENMT: [ENMT]



GI: [GI]

GU: [GU]










Vascular: Dorsalis pedis and posterior tibial pulses are [palpable, on-palpable] bilateral. Capillary filling

time with the leg elevated is [<5, 5,>5] seconds at the level of the digital tufts bilaterally. The skin temperature is [warm to warm, warm to cool, warm to cold] from the tibial tuberosity to the toes.

Musculoskeletal: The structure of the foot appears [rectus, supinated, pronated]. There [is, is not] pain

on palpation of the medial ankle [above, below, at] the malleolar level. There [is, is not] pain of the

medial heel at Baxter's nerve. The digits show [normal alignment, spreading of the 2nd and 3rd,

spreading of the 3rd and 4th, contracture of digits] [of the right foot, left foot, bilateral]. There is

[adequate, weak] muscle strength to manual examination [unilaterally, bilaterally]. [There is no pain with straight leg raise.]

Neurological: Deep tendon reflexes including Achilles and Patellar are [absent, normal, hyperreflexic]

[right, left, bilateral]. Epicritic sensation measuring light touch with Semmes Weinstein monofilament is

graded as [intact, diminished] in [1, 2, 3, 4, 5, 6, 7, 8, 9, 10] /10 places on the digits, forefoot, arch, heel,

and dorsum. Vibratory sensation measured with a 128Hx tuning fork is graded as [intact, diminished,

absent]. [Normal, Atrophic, Hypertrophic] muscle mass appreciated to both the lower extremity and

foot bilaterally. Percussion of the [lower extremity nerves is unremarkable, tibial nerve elicits

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parasthesias of the medial ankle, common peroneal nerve at the fibular head elicits parasthesias, sural nerve elicits parasthesias, deep peroneal nerve at the dorsum of the foot elicits parasthesias].

Dermatological: Skin turgor is [supple, atrophic, thin and shiny, cool, dry, moist, excessively perspiring].

Radiographs: Weight bearing radiographs reveal [digital contractures, no osseous pathology, splaying of

the digits, tumor, fracture, cystic changes, crowding of the metatarsal heads].

Impression: [Neuropathy, Tarsal Tunnel Syndrome, Baxter's neuritis, plantar fasciitis, Radiculopathy] [right, left, bilateral]

Treatment: I have discussed the condition and the conservative treatment options with the patient. At

this point I have recommended [further diagnostic testing, epidermal nerve fiber density biopsy testing,

EMG and NCV testing, chiropractic evaluation, radiographic limb length study, shoegear modifications,

oral supplement therapy, topical therapy]. I discussed more aggressive treatment options including

[corticosteroid injection therapy, sclerosing therapy, surgical nerve decompression]. I discussed the

risks, complications, and expected recovery course in detail. The plan at this point is to [live with the

numbness and delay treatments at this time, proceed with further testing, biopsy the skin for epidermal

nerve density, start oral supplement therapy, continue oral therapy, stop oral therapy, topical agent

therapy, referral to chiropractic specialist, referral to orthopedic specialist, referral for NCV EMG testing, referral to peripheral nerve specialist].

RTC [2 weeks, 3 weeks, 4 weeks, 12 weeks, PRN].

Surgery

Amputation at the MPJ Pre-op diagnosis: contracted digit [1, 2, 3, 4, 5] [right, left]


Procedure: amputation digit [1, 2, 3, 4, 5]


Assistants: none

Anesthesia: local

Hemostasis: digital tourniquet applied for [10, 20, 30, 40, 50, 60] minutes


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This patient presents for amputation of painful contracted digit. Patient states the toe is worsening and


to risk of infection, numbness, floppy toe, wound dehiscence, re -occurrence of deformity requiring

further surgery, or loss of digit. The patient understands these risks and elects to proceed with the procedure.

Procedure:


a half and half mixture of 0.5% Marcaine plain and 1% lidocaine plain in a digital block fashion. The foot was then scrubbed, prepped and draped in the normal sterile fashion.

Attention was directed to the dorsal aspect of the [1st, 2nd, 3rd, 4th, 5th] MPJ of the [right, left] foot. A

modified raquet type skin incision was made over the metatarso-phalangeal joint. The incision was

deepened through subcutaneous tissues care being taken to avoid all vital neural and vascular

structures. All bleeders were ligated or bovied as necessary. A transverse incision was made into the

extensor digitorum longus tendon. The proximal phalanx was disarticulated from the joint. The toe was

passed from the field and sent to pathology. The wound was flushed with copious amounts of normal

saline solution. All bleeders were bovied and ligated as needed. The area was inspected for completion

of amputation and it was noted to be excellent. The wound was repaired in layers and the skin was closed with 3-0 nylon in a simple interrupted technique.

A telfa and dry sterile dressing was applied. The tourniquet was release and a prompt hyperemic

response was noted to the effected toe. The patient was placed in a post-op shoe and a follow up visit

was scheduled. Instructions were given to remain non-weight-bearing, keep foot elevated, and to avoid getting the foot wet under any circumstances.

RTC [1, 2, 3, 4, 5, 6, 7, 14] days.

Apligraft Op report

Name: [Patient.Name] Date: [Date] Acct: [Patient.AcctNo]

Op report for Apligraft placement

Surgeon: Paul Brooks, DPM

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Pre op diagnosis: non -healing diabetic ulceration [right, left] foot

Post op Diagnosis: same

Procedure: application of apligraft to wound

Anesthesia: none

Indications for procedure: Patient is being treated for a wound that has stalled and is not healing. I gave

the option of apligraft placement to speed up the closure process and the patient agrees with this treatment plan. All risks vs. benefits were explained in detail.

Procedure:

Patient was brought into the operating room and placed on the operating table in the supine position.

After cleansing the wound with a wound wash product, the wound was probed to identify any sinus

tracts. The Apligraft was prepared per protocol. The graft was cut to size and placed over the granulating

wound bed making certain to cover the dermal epidermal junction. The graft was sutured in place with

3-0 nylon in a simple interrupted technique and cover with an adaptic non adherent dressing and then a

wet to dry dressing. [A piece of absorbent foam dressing was placed over the adaptic to absorb any

drainage.] The wound was secondarily dressed with a dry co ban.

The patient was given instructions for strict non weight bearing. RTC [1, 2, 3, 4] week(s).

Arthroplasty Digit


Pre-op diagnosis: Contracted digit [1, 2, 3, 4, 5] [right, left]


Procedure: Arthroplasty [1st, 2nd, 3rd, 4th, 5th] digit(s)


Assistants: none

Anesthesia: Local consisting of a half and half mixture of 1% lidocaine plain and 0.5% Marcaine plain



151

This patient presents for correction of painful contracted digit. Patient states the toe is worsening and



further surgery, or loss of digit. The patient understands these risks and elects to proceed with the

procedure. Oral and written consent form has been signed by the patient.

Procedure:



Attention was directed to the dorsal aspect of the [1st, 2nd, 3rd, 4th, 5th] toe of the [right, left] foot. A 2

cm linear skin incision was made over the proximal interphalangeal joint of the digit. The incision was


structures. All bleeders were ligated or bovied as necessary. The extensor tendon was transected at the

joint level. The collateral ligaments were swept, thus delivering the head of the proximal phalanx into

the surgical field. A ronguer was used to resect the head of the proximal phalanx, and this was [passed

from the field, passed from the field and sent to pathology]. The wound was flushed with copious

amounts of normal saline solution. The area was inspected for completion of arthroplasty and it was

noted to be excellent. The extensor tendon was re-approximated with 3-0 vicryl and the skin was closed

with 3-0 nylon in a simple interrupted technique. [The exact same procedure was performed on the other toe(s).]


response was noted to the effected toe(s). The patient was placed in a post-op shoe and a follow-up visit

was scheduled. Instructions were given to remain non-weight-bearing, keep foot elevated, and to avoid

getting the foot wet under any circumstances.

RTC [1, 2, 3, 4, 5, 6, 7, 14] days.

Biopsy epidermal Nerve density

Epidermal Nerve Fiber Density Biopsy


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Pre-op diagnosis: Neuropathy


Procedure: biopsy for epidermal nerve fiber density testing

Surgeon: [Paul D. Brooks DPM, Joshua Britt DPM]

Assistants: none

Anesthesia: local

Hemostasis: epinephrine in local anesthetic


This patient presents for biopsy. All risks vs. benefits have been explained in great detail including but

not limited to risk of infection, numbness, wound dehiscence, hematoma, or the need for further surgery. The patient understands these risks and elects to proceed with the procedure.

Procedure:

Patient was placed on the operating table in the supine position. The [right, left, right and left] ankle was

anesthetized 10 cm above the lateral malleolus with 0.5 mL of 2% lidocaine w/ epinephrine 1:100000.

The area was then prepped and draped in the normal sterile fashion.

Attention was directed to the lateral leg where skin at the biopsy site was stretched tight with my

fingers and a 3 mm punch biopsy full thickness through the dermis and subcutaneous tissue was made.

The skin was relaxed the wound took an ovoid shape. The specimen was removed with a forcep, care

taken to only grasp the subcutaneous fat and not damage the skin to reduce the chance of artifact on

pathological examination. The wound was flushed with copious amounts of high pressure normal saline

solution. The skin was re-approximated with 3-0 nylon in a simple interrupted technique. This was done bilaterally.

A dry sterile dressing was applied. Follow-up visit was scheduled. Instructions were given to avoid

getting the wound wet for 7 days. Patient is to contact the office of any signs of infection. Patient tolerated procedure well.

153

RTC 14 days for suture removal at which time we will likely have the results.

Biopsy Lesion


Pre-op diagnosis: [Lesion of uncertain behavior, Onychomycosis] [right, left] [leg, foot, toe, toenail]


Procedure: [excisional biopsy lesion, nail plate biopsy, punch biopsy lesion]


Assistants: none

Anesthesia: local

Hemostasis: [epinephrine in local anesthetic, none, digital tourniquet]


This patient presents for biopsy of [skin lesion, nail plate]. All risks vs. benefits have been explained in

great detail including but not limited to risk of infection, numbness, wound dehiscence, re -occurrence of

skin symptoms requiring further surgery. The patient understands these risks and elects to proceed with

the procedure.

Procedure:

Patient was placed on the operating table in the supine position. The foot was anesthetized with [3mL of

a half and half mixture of 0.5% Marcaine w/ epi and 1% Lidocaine plain,.5% Marcaine w/ epi, ).5%

Marcaine plain] in a regional block fashion. The foot was then scrubbed, prepped and draped in the

normal sterile fashion.

Attention was directed to the [HotSpots] where [1cm, 2cm, 3cm, 4cm, 5cm] [a semi elliptical skin

incision was made, the nail plate was freed from the soft tissue structures]. [The incis ion was deepened

through subcutaneous tissues care being taken to avoid all vital neural and vascular structures. All

bleeders were ligated or bovied as necessary. The dissection was performed deep to the level of the

dermis into the subcutaneous tissue. The lesion was removed and placed in a contained and sent for

biopsy. The wound was flushed with copious amounts of high pressure normal saline solution. The area

154

was once again inspected for completion of excision. The skin was re -approximated with 3-0 nylon in a

simple interrupted technique.] [The nail border was removed and placed in a specimen container and

sent to the lab for PAS and culture.]

A telfa and dry sterile dressing was applied. The patient was placed in a [post-op shoe, aircast,

protective dressing, sandal] and a follow-up visit was scheduled. Instructions were given to remain non-

weight-bearing today, keep foot elevated, and to avoid getting the foot wet to avoid infection for 3 days.

[RTC 5 days ,RTC 14 days, RTC prn, Will call patient with results.]

Chilectomy

Pre-op diagnosis: Hallux limitus [left, right]


Procedure: Resection Exostosis, chilectomy [left, right]


Assistants: none

Anesthesia: local

Hemostasis: ankle tourniquet applied for [10, 20, 30, 40, 50, 60] minutes


This patient presents for correction of painful hallux limitus. Patient states the toe joint is worsening and

limiting daily activities. [He, She] wants the spur removed in an effort to restore motion at the joint. All

risks vs. benefits have been explained in great detail including but not limited to risk of infection, DVT,

numbness, floppy toe, wound dehiscence, re-occurrence of deformity requiring further surgery, or loss of digit. The patient understands these risks and elects to proceed with the procedure.

Procedure:

Patient was placed on the operating table in the supine position. The foot was anesthetized with 10mL of a half and half mixture of 0.5% Marcaine w/ Pre-op diagnosis: Hallux limitus1, 2,3,4,5 right


155

Procedure: Resection Exocytosis, chilectomy 1, 2, 3, 4, 5 right


Assistants: none

Anesthesia: local

Hemostasis: ankle tourniquet applied for 30 minutes


This patient presents for correction of painful hallux limitus from a bony spur. Patient states the toe

joint is worsening and limiting daily activities. She wants the spur removed over the top of the foot as

this is what is hurting due to shoes rubbing this area. She does not want to remove the joint if it is

arthritic nor does her desire joint fusion. All risks vs. benefits have been explained in great detail

including but not limited to risk of infection, numbness, floppy toe, wound dehiscence, re-occurrence of

deformity requiring further surgery, or loss of digit. I explained the techniques to mitigate against DVT

including stationary exercises and moving about the airplane. IO explained there is still a high risk of DVT. The patient understands these risks and elects to proceed with the procedure.

Procedure:



Attention was directed to the dordal aspect of the 1st mpj of the right foot. A 5cm transverse skin

incision was made following the contour of the deformity. The incision was deepened through

subcutaneous tissues care being taken to avoid all vital neural and vascular structures. All bleeders were

ligated or bovied as necessary. A small hemostat was used to dissect down to capsule of the 1st MPJ. A

linear capulotomy was performed. It was noted the abundant heterotopic bone present. The head of the

metatarsal nor the base of the proximal phalanx had intact articular cartilage. A ronguer was used to

remove the boney lesion from the base of the proximal phalanx. An osteotome was used to remove the

spurring from the metatarsal head. Once adequate motion was restored, a rasp was used to restore the

normal boney contours of the metatarsal head. The joint and wound was flushed with copious amounts

of normal saline solution. The area was inspected for completion of resection of heterotopic bone and it

was noted to be excellent. The exact same procedure was performed on the other toe.

The capsule and sub cutaneous tissues where repaired with 3-0 vicryl in a continuous interlocking fashion. The skin was repaired with 3-0 nylon ina horizontal mattress technique.

156


response was noted to the effected toe(s). The patient was placed in a post-op shoe and a follow up visit

was scheduled. Instructions were given to remain non-weight-bearing, keep foot elevated, and to avoid getting the foot wet under any circumstances. She will follow up with her pcp in Alaska.

i 1:200000 and 1% lidocaine w/ epi 1:100000 in a Mayo block fashion. The foot was then scrubbed, prepped and draped in the normal sterile fashion.

Attention was directed to the dordal aspect of the [right, left] 1st metatarsophalangeal joint. A

5cmcurvilinear skin incision was made following the contour of the deformity. The incision was


structures. All bleeders were ligated or bovied as necessary. A small hemostat was used to dissect down

to capsule of the 1st MPJ. A linear capulotomy was performed. It was noted to have abundant

heterotopic bone present. The head of the metatarsal [had intact cartilage surface, had an

osteochondral defect, was devoid of articular cartilage] and the base of the proximal phalanx [had intact

cartilage surface, had an osteochondral defect, was devoid of articular cartilage]. A ronguer was used to

remove the heterotopic bone from the base of the proximal phalanx. An osteotome was used to remove

the spurring from the metatarsal head. Once adequate motion was restored, a rasp was used to restore

the normal boney contours of the metatarsal head. The joint and wound was flushed with copious

amounts of normal saline solution. The area was inspected for completion of resection of heterotopic

bone and it was noted to be excellent.

The capsule was repaired with 3-0 vicryl in a continuous running fashion and sub cutaneous tissues

where repaired with 3-0 vicryl in a continuous running fashion. The skin was repaired with 3-0 nylon in a horizontal mattress technique.

A telfa and dry sterile dressing was applied. The tourniquet was released and a prompt hyperemic

response was noted to the toe(s). The patient was placed in a post-op shoe and a follow up visit was

scheduled. Instructions were given to remain non-weight-bearing, keep foot elevated, and to avoid getting the foot wet under any circumstances.

157

Informed Consent – Achilles Tendon Repair


This is an informed consent document that has been prepared to help inform you concerning your

surgery, its risks, and alternative treatment. Dr. Brooks has recommended surgical intervention and has

planned to perform a [repair of the Achilles Tendon, debridement of the Achilles Tendon, repair

ruptured Achilles tendon, resection calcaneal spur, resection haglund's deformity], of the [right, left] foot under [local, MAC, general] anesthesia.

INTRODUCTION

Achilles tendonitis is an inflammation caused by excessive stretching of the Achilles tendon. When the

Achilles tendon is excessively stretched, this can cause Achilles tendonitis, which can also lead to heel

pain, arch pain, and heel spurs. Calcaneal spurs are commonly associated with Achilles tendinitis. Your

surgeon will determine if resection of the spur is needed at the time of surgery.

ALTERNATIVE TREATMENT

Alternative forms of non-surgical treatment include proper orthotics, stretching exercises, taping,

steroid injections and anti-inflammatory treatment. Risks and potential complications are associated

with alternative forms of treatment.

RISKS OF SURGERY

Every surgical procedure involves a certain amount of risk, and it is important that you understand the

risks involved. An individual's choice to undergo a surgical procedure is based on the comparison of the

risk to potential benefit. Although the majority of patients do not experience these complications, the following is a list of potential complications.

Bleeding - It is possible, though unusual, to experience an increased amount of bleeding during

or after surgery. Should post-operative bleeding occur, it may require emergency treatment to

drain any accumulated blood (hematoma). Unless authorized by your primary care physician,

do not take any aspirin or aspirin products for ten days prior to surgery as it may contribute to a greater risk of bleeding.

Infection - Infection is a rare complication after surgery, however, should an infection occur, additional treatment including antibiotics or additional surgery may be necessary.

158

Changes in sensation - Temporary loss of sensation around the operative site is expected

following surgery, however, this sensation should return over the following weeks or months. Prolonged loss of sensation is a rare, but a possible complication.

Scarring - All surgery leaves scars, some more visible than others. Although good wound healing

after a surgical procedure is expected, abnormal scars may occur within the skin and deeper

structures. Additional treatments including surgery may be needed to treat scarring.

Surgical anesthesia - Both local and general anesthesia involve risk. There is the possibility of

complications, injury, and even death from all forms of surgical anesthesia or sedation.

Smoking - Smokers have a greater risk of problems with wound healing. It is advised to stop smoking two weeks prior and post-surgery to decrease risk.

ADDITIONAL SURGERY NECESSARY

In some situations, it may not be possible to achieve optimal results with a single surgical

procedure. Should complications occur, additional surgery or other treatments may be necessary. Even

though risks and complications occur infrequently, the risks cited are the ones that are particularly associated with this kind of surgery.

Other complications and risks can occur but are uncommon. The practice of medicine and surgery is not

an exact science. Although good results are expected, there cannot be any guarantee or warranty expressed or implied on the results that may be obtained.

FINANCIAL RESPONSIBILITIES

The cost of surgery involves several charges for the services provided. Depending on whether the cost

of surgery is covered by an insurance plan, you will be responsible for necessary co-payments,

deductibles, and charges not covered. Payment or other financial arrangement must be received prior to

surgery.

DISCLAIMER

Informed-consent documents are used to communicate information about the proposed surgical

treatment of a disease or condition along with disclosure of risks and alternative forms of

159

treatment(s). The informed-consent process attempts to define principles of risk disclosure that should generally meet the needs of most patients in most circumstances.

However, informed-consent documents should not be considered all inclusive in defining other methods

of care and risks encountered. Your podiatrist may provide you with additional or different information, which is based on all the facts in your particular case and the state of medical knowledge.

Informed-consent documents are not intended to define or serve as the standard of care. Standards of

medical care are determined on the basis of all of the facts involved in an individual case and are subject

to change as scientific knowledge and technology advance and as practice patterns evolve.

It is important that you read the above information carefully and have all of your questions answered before signing the consent.

I have read the above information and consent to the procedure knowing the risks and benefits.

Patient____________________________________________________Date_____________

Physician__________________________________________________Date_____________

Witness____________________________________________________Date_____________

CRYOSURGERY - Neuroma

CRYOSURGERY OPERATIVE REPORT - NEUROMA

PATIENT NAME:[Patient.Name]

PATIENT ACCT #: [Patient.AcctNo]

DATE OF SX: [Long Date]

PRE/POST-OP DX: Neuroma, [2nd, 3rd*,4th], [Right, Left, Bilateral] Foot

PROCEDURE: Cryosurgery Neuroplasty, [2nd,3rd*,4th] Intermetatarsal Space, [Right, Left, Bilateral]

160

COMPLICATIONS: [None*, persistent bleeding]

SURGEON: [Bruce M. Nigro DPM, Paul D. Brooks DPM]

ASSISTANT: none

PREOPERATIVE DIAGNOSIS:

1) Nerve entrapment within soft tissue, [2nd, 3rd, 4th] intermetatarsal space, plantar nerves, [right, left,

bilateral].

2) Morton's neuroma [2nd, 3rd, 4th] intermetatarsal space, plantar nerves, [right, left, bilateral].

POSTOPERATIVE DIAGNOSIS:

1) Nerve entrapment within soft tissue, [2nd, 3rd, 4th] intermetatarsal space, plantar nerves, [right, left,

bilateral].

2) Morton's neuroma [2nd, 3rd, 4th] intermetatarsal spaces, plantar nerves, [right, left, bilateral] foot.

PROCEDURE:

1) Surgical release of soft tissue entrapment and scar tissue for nerve decompression, [2nd, 3rd, 4th] intermetatarsal space [right, left, bilateral] foot.

2) Cryosurgical neuroablation, [2nd, 3rd, 4th] intermetatarsal spaces plantar nerves, [right, left,

bilateral] foot.

INDICATIONS: Chronic pain and failed previous conservative therapies and treatments.

ANESTHESIA: 1% lidocaine with epinephrine 1:100,000 dilution.

BLOOD LOSS: Negligible, less than 0.5 cc.

COMPLICATIONS: None

CONDITION: Stable.

DESCRIPTION of PROCEDURE:

The patient was afforded a final opportunity for informed consent prior to performing the

procedure. The medical logic and basis for the proposed procedure were again reviewed with the

patient. Risks, complications, alternatives, and post-operative management and expectations following

the Cryoanalgesia procedure were discussed. Specifically, failure of the procedure to provide the

161

desired result, the possibility of infection, the possibility of the condition worsening as a result of the

procedure, and the possible need for additional procedures were all discussed at length. The patient

was provided no guarantees as to outcome. The patient understands that people react differently to

surgery of any kind, and that their response to the proposed procedure may not exactly follow the

expected course post operatively. Complications may include delayed healing, numbness, abscess

formation at the site of Cryoanalgesia application, superficial necrosis of skin, deep tissue necrosis, all of

which will require additional medical attention should they occur. The patient understands that the

results of the procedure may be numbness in the previously painful area. The patient agrees that

numbness would be preferable to chronic pain. Of their own free will, the patient provided both verbal

and written consent to the performance of the Cryoanalgesia procedure, being satisfied that all questions had been thoroughly answered and addressed.

At this time the [right, left] foot was examined and the areas of maximal tenderness of the [right,

left][2nd,3rd,4th] interspace was identified and so marked with a surgical marking pen. 3 cc of 1%

lidocaine with epinephrine, 1:100,000 dilution were then infiltrated from dorsal proximal to plantar

distal within the [2nd, 3rd, 4th] interspace along the course of the involved nerves. The [right, left] foot was then prepped and draped in the usual aseptic manner.

Attention was then directed to the distal aspect of the [right, left] [2nd, 3rd, 4th] webspace where a

Beaver 64 blade was carefully introduced from distal to proximal to the level of the DTIL which was then transected to achieve nerve decompression.

Next a 14- gauge coated angiocatheter was then inserted from proximal dorsal over the distal [ right,

left] [2nd, 3rd, 4th] interspace and carefully advanced in a plantar distal direction to towards the point

of maximal tenderness and enlarged nerve tissue. The Cryoprobe device was then inserted into the

channel that had been created by the catheter and then advanced to the level of the enlarged swollen

nerve tissue just deep to the now released DTIL. The Cryoprobe was then activated for a 2-minute freeze

cycle applied directly to the irritated and inflamed nerve tissue in the area previously marked as

maximally tender. A1 minute defrost cycle was followed by a second 2-minute freeze cycle which was

applied after repositioning the Cryoprobe to a more proximal and dorsal location within the channel.

The Cryoprobe device was again allowed to adequately defrost for approximately 60 seconds and then

removed from the foot. [0.5, 1.0] cc's of dexamethasone phosphate was infiltrated into the surgical site to reduce post-operative inflammation and swelling. No bleeding occurred during the procedure.

[An identical procedure as described above was then performed in the [ right, left] [2nd, 3rd, 4th]

interspace without addition deletion or exemption.] The surgical site(s) were then medicated with

antibiotic ointment and a dry sterile mildly compressive dressing applied. The patient tolerated the

procedure without complication. There was no pain, discomfort, or distress experienced by the patient

before, during, or after the procedure. Reduction in pain was noted by the patient upon

ambulation. Written and oral post-operative instructions were provided to the patient. [He, She] was

162

advised to use over-the-counter pain medication if tolerated for pain reduction and anti-inflammatory

properties. The patient was cautioned about potential GI side effects from NSAIDS. [ He, She] was

advised to keep the foot dry until the morning and then to reapply antibiotic ointment to the surgical

sites under a dry sterile dressing following a brief shower over the next several days. The patient was

urged to report immediately if any complications are noted such as bleeding or signs of infection. [He,

She] was specifically advised to look for increased redness, swelling, pain, drainage, or red streaks

proximal to the surgical sites. [He, She] was instructed on how to contact me after hours if needed by

phoning our main office telephone number (850) 479-6250. The patient was given a follow up

appointment but was urged to call prior to that time if [he, she] has any concerns. The patient was

advised to reduce activity as much as possible and remain in the surgical shoe that was dispensed to help protect the foot from undo trauma post operatively.

______________________________________

[Bruce M. Nigro DPM, Paul D Brooks DPM]

ENFD post op 1

Chief Complaint: The patient presents today for the first post-biopsy recheck following [a right calf, a left

calf, bilateral calf] skin [biopsy, biopsies] for epidermal nerve fiber density testing. The patient relates no

problems or signs of infection. The patient [has, has not] adhered to the post-operative instructions.

[He, She] reports no pain at the biopsy sites. The patient has no new complaints today.

Objective: The patient's neurovascular status is unchanged from the previous visit. The biopsy [ site,

sites] were found to be free from signs of infection. There is no active drainage, purulent discharge, or

malodor noted. Minor localized erythema within normal parameters is noted. The sutures are intact and

the wound edges are well coapted. No hematoma, abscess or blister formation noted. The region is non-tender. No open lesions were noted to either lower extremity.

Test Results: ENFD test results pending.

Impression: Status post [right calf, left calf, bilateral calf] skin [biopsy, biopsies] for epidermal nerve fiber density testing, healing satisfactorily with no signs of infection, or complications.

Treatment: The patient was advised that it is now ok to allow the area to get wet briefly while

showering, but not to bathe or swim at this point. Instructions for ongoing daily care now include

application of a small thinly distributed quantity of topical antibiotic ointment to the biopsy site after

showering followed by coverage with a small sterile dressing. Will follow up in one week for suture

removal and to discuss test results if available. I advised the patient to call and RTC ASAP if concerns or problems arise.

163

ENFD post op 2

Chief Complaint: Patient presents today for 2 week follow up of skin biopsy for epidermal nerve fiber

density testing. The patient relates no problems or signs of infection and [has, has not] adhered with all

post-operative instructions. The biopsy sites [are, are not] painful. The patient has no new pedal

complaints at this time.


Medications: [Meds]




ROS:

Eyes: [Eyes]

GI: [GI]

GU: [GU]







Objective: The patient's neurovascular status is unchanged from the previous visit. The biopsy sites are

dry and well-healed. There is [no, minimal] localized erythema remaining. There are no signs of infection noted. There are no open lesions noted to either lower extremity.

Test Results: Most recent ENFD test results are:

Right calf - nerve fibers/mm in the 3mm sample.

Left calf --- nerve fibers/mm in the 3mm sample.

Previous ENFD results were:

Right calf -

164

Left calf ---

Impression: 2 weeks status post skin biopsy for epidermal nerve fiber density testing. Results are

[normal, consistent with early onset small fiber neuropathy, consistent with advanced small fiber neuropathy].

Treatment:

1) Sutures were removed. I applied topical antibiotic ointment and a dry dressing to biopsy sites. The

restrictions on bathing and swimming are now removed and the patient is clear to get the area wet as

before. Patient was advised to continue to inspect the biopsy sites daily and notify the office

immediately if any signs of infection at the biopsy sites are noted.

2) Evaluation and management encounter undertaken to discuss test results and the diagnosis of small

fiber neuropathy now confirmed and quantified with the ENFD test results as noted above. We

discussed nutritional nerve support including [NeuRX-TF, Neuremedy, Metanx*]. I recommended L-

Methylfolate medical food supplementation and advised the patient of the potential for nerve

regeneration with time. I discussed the need for follow-up ENFD testing in 6-12 months. The patient

was advised to begin taking [NeuRX-TF, Neuremedy, Metanx*] as directed daily. The patient was given a

prescription for Metanx # 90 with instructions to take 2 daily with 2 refills. The coupon program information was provided to defray some of the cost to the patient.

3) The patient was advised of the risks associated with the Loss of Protective Sensation (LOPS) from the

small fiber neuropathy. The patient was advised to perform diligent daily inspection of feet and legs, to

wear proper shoe gear at all times, to avoid barefoot activity including in the home, to avoid self-care,

and to seek immediate medical attention for any problems found to reduce the likelihood of suffering the complications associated with small fiber peripheral neuropathy and LOPS.

Recommended patient RTC in [1 week, 2 weeks, 1 month, 2months, other].

Exostectomy

Patient: [Patient.Name] DOB: [Patient.Birthdate] Account No: [Patient.AcctNo]

Date: [Date]

Operative Report

Subjective: This [patient.Age] year-old [patient.Gender] returns today for elective surgery for removal

of painful exostosis on [the 2nd toe, the 3rd toe, the 4th toe, the 5th toe] of [the left foot, the right foot,

bilateral feet]. I have previously discussed the procedure with the patient and [patient.heshe] wishes to

proceed. I discussed the benefits and possible risks of the procedure including the possibility of vascular

compromise, prolonged swelling, infection and reoccurrence of the [deformity, deformities]. The informed consent was signed today and a copy of this is in the patient's chart.

165

Surgeon: Patrick Barnes, DPM

Assistant: [Cindy Auffart, Denise Harold, Linda Wright, Cassandra McClarnon].

Pre-operative Diagnosis: Exostosis [left, right, bilateral] [2nd toe, 3rd toe, 4th toe, 5th toe].

Post-operative Diagnosis: Same.

Procedure: Exostectomy [left, right, bilateral] [2nd toe, 3rd toe, 4th toe, 5th toe].

Anesthesia: Local. Total amount used: [1,2,3,4,5,6,7,8,9,10] cc's.

Hemostasis: [Ankle tourniquet at 250 mm Hg, Digital tourniquet, Digital tourniquets].

EBL: [<1 cc, <2cc, <3cc].

Procedure:

The patient was taken to the operating room and placed on the chair in a supine position. A local

anesthetic block was then administered to the base of [the 2nd toe, the 3rd toe, the 4th toe, the 5th

toe] [left, right, bilateral] utilizing 3 cc's of [.5% Marcaine with epinephrine, 1% lidocaine plain] to the

base of each [toe, of the toes]. The [foot was, feet were] then prepped in the usual sterile

manner. Following application of [an ankle tourniquet, a digital tourniquet] to [the left foot, the right

foot], a #15 blade was used to make an incision over the dorsum of [the 4th toe, the 5th toe]. The skin

wedge created by these 2 incisions was excised. The medial and lateral margins of the wound was then

underscored. The incision was freed both proximally and distally. The head of the proximal phalanx was

then cut and excised with a bone cutting forceps. All roughened portions of the bone were smoothed

with a bone rasp. The wound was flushed with saline. I reapproximated the EDL tendon with [4.0

Nylon,4.0 Polysorb]. I reapproximated the skin with [4.0 Nylon,5,0 Nylon]. I dressed the incision with

telfa, gauze, and coban. The [digital tourniquet, ankle tourniquet] was released. The patient tolerated

the procedure and anesthesia well. [patient.HeShe] [was*, was not] dispensed a surgical shoe. Written and verbal instructions were given.

Return: [patient.HeShe] is to return in 1 week for f/u.

166

Exostectomy/Condylectomy of Toe op-report


Date: [Date]

Operative Report


of [a painful exostosis on, an exostosis causing ulceration on, an exostosis causing a painful callous on]

[the 1st, the 2nd toe, the 3rd toe, the 4th toe, the 5th toe] of [the left foot, the right foot, both feet]. I

have previously discussed the procedure with the patient and [patient.heshe] wishes to proceed. I

discussed the benefits and possible risks of the procedure including the possibility of vascular

compromise, prolonged swelling, infection, failure of the procedure to provide the desired result, and

the possible need for additional procedures. The patient was afforded another opportunity for

questions and answers. He provided both verbal and written informed consent for the procedure.

Surgeon: [Bruce Nigro DPM, Paul Brooks DPM]

Assistant: None

Pre-operative Diagnosis: [Exostosis, unspecified digital deformity, ulceration] [left, right, bilateral] [1st toe, 2nd toe, 3rd toe, 4th toe, 5th toe].


Procedure: Exostectomy/condylectomy [left, right, bilateral] [1st toe, 2nd toe, 3rd toe, 4th toe, 5th toe].

Anesthesia: Local only. Total amount used: [1, 2, 3, 4, 5, 6, 7, 8, 9, 10] cc's.

Hemostasis: [None, Ankle tourniquet at 250 mm Hg, Digital tourniquet].

EBL: [<1 cc, <2cc, <3cc].

Procedure:

The patient was taken to the operating room and placed on the table in the supine position. The foot

and all webspaces were washed with isopropyl alcohol which was allowed to air dry. A local anesthet ic

block was then administered to the base of [the 1st,the 2nd toe, the 3rd toe, the 4th toe, the 5th toe]

[left, right, bilateral] utilizing 3 cc's of 0.5% Marcaine plain and 1% lidocaine plain in a 1:1 ratio to the

base of [the toe, each of the toes]. The [foot was, feet were] then prepped with betadine solution and draped in the usual sterile manner.

Attention was then directed to the [medial, lateral] aspect of the [right, left] [1st toe,2nd toe,3rd toe,4th

toe,5th toe] at the level of the [PIPJ,DIPJ] where a 3 mm longitudinal and linear incision was made

167

overlying the exostosis to be removed. The incision was sharply deepened down to the level of the

periosteum which was linearly incised and reflected to expose the enlarged portion of bone. The Osad a

drill was chosen for its high torque low rpm features. A Shannon 44 burr was introduced into the incision

and placed against the exposed bone. The drill was activated and the enlarged bone was reduced slowly.

Manual evaluation and inspection was used to determine the correct amount of osseus reduction

needed to accomplish the goal of reducing interdigital pressure sufficiently to promote healing and

resolution of the chronic [pain, hyperkeratosis, ulceration] noted at the site. The wound was then

flushed with copious quantities of sterile saline to remove all bone paste/chips created. The skin was

reapproximated and sutured closed with 4.0 nylon in horizontal mattress fashion. Betadine solution was

again applied to the site. A dry mildly compressive sterile dressing was applied to the toe and the right

foot. The patient tolerated the procedure and anesthesia well. [patient.HeShe] [was*, was not]

dispensed a surgical shoe. Written and verbal instructions were given stressing the need to return

immediately home, keep the foot elevated and dry, to apply ice today to the dorsum of the foot, and to

reduce activity substantially until seen for his first post-op recheck. He was advised that should his

dressing get wet it will need to be changed promptly. He was advised to use OTC Tylenol or Ibuprofen

sparingly as needed for pain control.

Return: [patient.HeShe] is to return in [5 days, 1 week, 11 -14 days] for f/u. He was advised to return

sooner if problems are noted.

Exostosis Distal toe

Pre-op diagnosis: Exostosis [1, 2, 3, 4, 5] [right, left]


Procedure: Resection Exostosis [1, 2, 3, 4, 5] [right, left]


Assistants: none

Anesthesia: local



This patient presents for correction of painful contracted boney spur. Patient states the toe is worsening

and limiting daily activities. All risks vs. benefits have been explained in great detail including but not

limited to risk of infection, numbness, floppy toe, wound dehiscence, re -occurrence of deformity

requiring further surgery, or loss of digit. The patient understands these risks and elects to proceed with

the procedure.

168

Procedure:


a half and half mixture of 0.5% Marcaine plain and 1% lidocaine plain in a digital block fashion. The foot

was then scrubbed, prepped and draped in the normal sterile fashion.

Attention was directed to the distal aspect of the [1st, 2nd, 3rd, 4th, 5th] toe of the [right, left] foot. A 1

cm transverse skin incision was made following the resting skin tension lines. The incision was deepened


bleeders were ligated or bovied as necessary. A small hemostat was used to dissect down to the

periosteum. A ronguer was used to remove the boney lesion and it was removed from the field and sent

to pathology. The wound was flushed with copious amounts of normal saline solution. The area was

inspected for completion of resection and it was noted to be excellent. [The exact same procedure was performed on the other toe.]




RTC [1, 2, 3, 4, 5, 6, 7, 14] days.

Flexor Tenotomy


Pre-op diagnosis: contracted digit [1, 2, 3, 4, 5] [right, left]


Procedure: flexor tenotomy [1, 2, 3, 4, 5]


Assistants: none

Anesthesia: local



169

This patient presents for correction of painful contracted digit. Patient states the toe is worsening and


to risk of infection, numbness, floppy toe, wound dehiscence, re-occurrence of deformity requiring


Procedure:



Attention was directed to the plantar aspect of the [1st, 2nd, 3rd, 4th, 5th] toe of the [right, left] foot. A

1 cm transverse skin incision was made under the crease of the digit. The incision was deepened


bleeders were ligated or bovied as necessary. A small hemostat was used to dissect down to the flexor

digitorum longus tendon. The [FDL, FDB, both the FDL and FDB] tendon(s) was grasped and brought out

into the surgical field and sharply transected with a 15 blade. This allowed the flexion contracture

pressure to be taken out of the digit. The wound was flushed with copious amounts of normal saline

solution. The area was inspected for completion of tenotomy and it was noted to be excellent. The skin

was closed with 3-0 nylon in a simple interrupted technique. [The exact same procedure was performed on the other toe.]

A telfa and dry sterile dressing was applied. The tourniquet was released and a prompt hyperemic



RTC [1, 2, 3, 4, 5, 6, 7, 14] days.

Metatarsal Ostectomy


Date: [Date]

Operative Report


of [a painful exostosis on, an exostosis causing ulceration on, an exostosis causing a painful callous on]

170

[the 1st, the 2nd toe, the 3rd toe, the 4th toe, the 5th toe] of [the left foot, the right foot, both feet]. I

have previously discussed the procedure with the patient and [patient.heshe] wishes to proceed. I

discussed the benefits and possible risks of the procedure including the possibility of vascular

compromise, prolonged swelling, infection, failure of the procedure to provide the desired result, and

the possible need for additional procedures. The patient was afforded another opportunity for

questions and answers. He provided both verbal and written informed consent for the procedure.

Surgeon: [Bruce Nigro DPM, Paul Brooks DPM]

Assistant: None

Pre-operative Diagnosis: [Exostosis, unspecified digital deformity, ulceration] [left, right, bilateral] [1st toe, 2nd toe, 3rd toe, 4th toe, 5th toe].


Procedure: Exostectomy/condylectomy [left, right, bilateral] [1st toe, 2nd toe, 3rd toe, 4th toe, 5th toe].

Anesthesia: Local only. Total amount used: [1, 2, 3, 4, 5, 6, 7, 8, 9, 10] cc's.

Hemostasis: [None, Ankle tourniquet at 250 mm Hg, Digital tourniquet].

EBL: [<1 cc, <2cc, <3cc].

Procedure: The patient was taken to the operating room and placed on the table in the supine

position. The foot and all webspaces were washed with isopropyl alcohol which was allowed to air dry.

A local anesthetic block was then administered to the base of [the 1st,the 2nd toe, the 3rd toe, the 4th

toe, the 5th toe] [left, right, bilateral] utilizing 3 cc's of 0.5% Marcaine plain and 1% lidocaine plain in a

1:1 ratio to the base of [the toe, each of the toes]. The [foot was, feet were] then prepped with betadine solution and draped in the usual sterile manner.

Attention was then directed to the [medial, lateral] aspect of the [right, left] [1st toe,2nd toe,3rd toe,4th

toe,5th toe] at the level of the [PIPJ,DIPJ] where a 3 mm longitudinal and linear incision was made

overlying the exostosis to be removed. The incision was sharply deepened down to the level of the

periosteum which was linearly incised and reflected to expose the enlarged portion of bone. The Osada

drill was chosen for its high torque low rpm features. A Shannon 44 burr was introduced into the incision

and placed against the exposed bone. The drill was activated and the enlarged bone was reduced slowly.

Manual evaluation and inspection was used to determine the correct amount of osseus reduction

needed to accomplish the goal of reducing interdigital pressure sufficiently to promote healing and

resolution of the chronic [pain, hyperkeratosis, ulceration] noted at the site. The wound was then

flushed with copious quantities of sterile saline to remove all bone paste/chips created. The skin was

reapproximated and sutured closed with 4.0 nylon in horizontal mattress fashion. Betadine solution was

again applied to the site. A dry mildly compressive sterile dressing was applied to the toe and the right

foot. The patient tolerated the procedure and anesthesia well. [patient.HeShe] [was*, was not]

171

dispensed a surgical shoe. Written and verbal instructions were given stressing the need to return

immediately home, keep the foot elevated and dry, to apply ice today to the dorsum of the foot, and to

reduce activity substantially until seen for his first post-op recheck. He was advised that should his

dressing get wet it will need to be changed promptly. He was advised to use OTC Tylenol or Ibuprofen sparingly as needed for pain control.

Return: [patient.HeShe] is to return in [5 days, 1 week, 11 -14 days] for f/u. He was advised to return sooner if problems are noted.

Post-op Arhtrodesis


Subjective: This is the [first, second, third, fourth, fifth, sixth, seventh, eighth, ninth, tenth] post-surgical

visit status-post arthrodesis of the [IPJ of hallux, MPJ of hallux, PIPJ of the 2nd digit, PIPJ of the 3rd digit,

PIPJ of the 4th digit, 1st metatarso-cuneiform joint, talo-navicular joint, subtalar joint, calcaneo-cuboid

joint, ankle joint] of the [right, left] foot reconstructive surgery. The patient denies any F/C/N/V/CP/SOB/Calf pain or tenderness.

Objective: The dressings are removed and all surgical sites [are well coapted with intact sutures,

dehisced]. The surgical sites appear [minimally swollen with ecchymosis which are consistent with the

level of surgical intervention, are moderately swollen with surrounding erythema, necrotic skin

edges. Stable osteotomy sites without crepitation or instability appreciated with range of motion. Ideal

correction of the deformity is apparent. Negative Homan sign, no pain on medial -lateral or anterior-

posterior compression of the calf musculature, no warmth or palpable cords evident eithe r bilateral

lower extremity.

Radiographic examination: 2 views reveals [stable internal fixation and maintained correction of the

deformity, dislocated osteotomy and fixation].

Assessment: status post arhtrodesis [first, second, third, fourth, fifth, sixth, seventh, eighth, ninth, tenth]

post-surgical visit status-post arthrodesis of the IPJ of hallux, MPJ of hallux, PIPJ of the 2nd digit, PIPJ of

the 3rd digit, PIPJ of the 4th digit, 1st metatarso-cuneiform joint, talo-navicular joint, subtalar joint, calcaneo-cuboid joint, ankle joint] of the [right, left] foot.

Plan: Status-post corrective/reconstructive surgery, [doing well, complications have occurred]. I

cleansed the patient's foot and will allow bathing starting in 6 -10 days. The patient was given post-

172

operative instructions for home therapy and to leave the Steri -strips intact until they come off with

wear. The patient is allowed to return to closed shoes to tolerance. We will see them in follow-up in 2-

3 weeks’ time for serial x-rays to monitor the healing process, or sooner should problems arise.

Post-op Bunionectomy


Subjective: This is the first post-surgical visit status post-[Austin bunionectomy, Reverdin-Laird

bunionectomy, arthrodesis 2nd digit, arthrodesis 3rd digit, arthrodesis 4th digit, arthroplasty 5th digit] reconstructive surgery. The patient denies any F/C/N/V/CP/SOB/Calf pain or tenderness.

Objective: The dressings are removed and all surgical sites [are well coapted with intact sutures,

dehisced]. The surgical sites appear [minimally swollen with ecchymosis which are consistent with the

level of surgical intervention, are moderately swollen with surrounding erythema, with necrotic skin

edges]. No crepitation or instability appreciated with range of motion. Range of motion of the joint is

[improved, unchanged swollen and stiff] and measured as [5-10,10-15,15-20,20-25,25-30,30-35,35-

40,40-45,45-50] degrees. Ideal correction of the deformity is apparent. Negative Homan sign, no pain on

medial-lateral or anterior-posterior compression of the calf musculature, no warmth or palpable cords evident either bilateral lower extremity.

Radiographic examination: reveals stable internal fixation and maintained correction of the deformity

without evidence of fracture when compared with the immediate postoperative x -rays.

Assessment: status post [bunionectomy, arthrodesis 2nd digit, arthrodesis 3rd digit, arthrodesis 4th

digit, arthroplasty 5th digit].

Plan: Status-post corrective/reconstructive surgery, doing well. I cleansed the wound and applied

povodone iodine the incision line and will allow bathing starting at 10 days post-op. The patient was

given post-operative instructions for home therapy consisting of passive joint range of motion. Patient

to change this dressing in 3 days then change daily with light dressing, and to leave the Steri -strips intact

until they come off with wear. [The patient was dispensed an aircast SP pneumatic walker and

instructed to use this for 2 weeks with crutches then d/c crutches but remain in walker, Patient elects to

wear the post-op shoe dispensed at the facility. We will see them for follow-up in [2-3] weeks’ time or sooner should problems arise.

173

Post-op Visit 3


Subjective: This is the third post-surgical visit status-post [osseous, soft tissue] reconstructive

surgery. The patient denies any F/C/N/V/CP/SOB/Calf pain or tenderness.

Objective: The surgical sites are maturing and without evidence of hypertrophy, tenderness, or card inal

signs of infection. Resolving edema present consistent with the patient's level of surgery and time frame

since surgery. Stable osteotomy sites without crepitation or instability appreciated with stressed range

of motion. Ideal correction of the deformity is apparent. Negative Hohman sign, no pain on medial -

lateral or anterior-posterior compression of the calf musculature, no warmth or palpable cords evident

either bilateral lower extremity.

Radiographic examination: reveals stable internal fixation and maintained correction of the deformity without evidence of fracture when compared with the immediate and subsequent post-operative x-rays.

Assessment: s/p [bunionectomy, arthrodesis digit, derotational arthroplasty, arhtroplasty, resection

exostosis, excision neuroma, removal retained hardware, permanent ingrown nail procedure, flexor tenotomy] [1, 2, 3, 4, 5] [right, left]

Plan: Status-post corrective/reconstructive surgery doing well. The patient was once again instructed to

perform home therapy. The patient is encouraged to remain in closed shoes to tolerance. We will see them in follow-up in 3 months’ time-frame for final evaluation or sooner should problems arise.

Post-op Visit 4


Subjective: This is the fourth post-surgical visit status-post [osseous, soft tissue] reconstructive

surgery. The patient denies any F/C/N/V/CP/SOB/Calf pain or tenderness.

Objective: The surgical sites are fully matured and without evidence of hypertrophy, tenderness, or

cardinal signs of infection. Resolved edema with stable surgical sites noted without crepitation or

instability appreciated with stressed range of motion. Ideal correction of the deformity is apparent and

maintained. Negative Hohman sign, no pain on medial-lateral or anterior-posterior compression of the calf musculature, no warmth or palpable cords evident either bilateral lower extremity.

174

Radiographic examination: reveals stable internal fixation, progressive osseous healing, and maintained

correction of the deformity without evidence of fracture when compared with the immediate and

subsequent post-operative x-rays.


exostosis, excision neuroma, removal retained hardware, permanent ingrown nail procedure, flexor

tenotomy] [1, 2 ,3 ,4 ,5][right, left]

Plan: Status-post corrective/reconstructive surgery doing well. The patient was once again instructed to

perform home therapy and may return to any and all activities as they see fit. We will see them in follow-up in on a PRN basis or sooner should problems arise.

Post-op Visit Follow-up


Subjective: This is the [first, second, third, fourth, fifth, sixth, seventh, final] post-surgical visit status-

post [osseous, soft tissue, toenail] reconstructive surgery. The patient [denies any F/C/N/V/SOB, admits to some pain in the calf region, admits to constitutional symptoms, admits to fever and chills].

Objective: Dressing today is [intact, intact with strike through bleeding, intact but soiled as evidence of

non-compliance from weight bearing, not present against orders, not present as patient has healed

sufficiently and is no longer needed]. Incision line is [unremarkable, well coapting, minimally swollen,

ecchymotic consistent with the level of surgical intervention, erythematous, dehisced, with minimal

edema and resolved ecchymosis consistent with the level of surgical intervention]. [Stable osteotomy

sites without crepitation or instability appreciated with stressed range of motion, Movement of

osteotomy site with stressed range of motion, Ideal correction of the deformity is apparent, unfavorable

surgical outcome]. Patient Vitals: [Vitals].

Radiographic examination: [2 views, 3 views] reveals [stable internal fixation, maintained correction of

the deformity, movement of the osteotomy site, hardware in favorable position, hardware in unfavorable position] when compared with the immediate and subsequent post-operative x-rays.


exostosis, excision neuroma, removal retained hardware, permanent ingrown nail procedure, flexor tenotomy, chilectomy, endoscopic plantar fasciotomy, excison foreign body] [1, 2, 3, 4, 5] [right, left]

175

Plan: Status-post corrective/reconstructive surgery [doing well, having complications]. [Sutures

removed, Sutures left intact, Steri strips removed, sterile dressing applied after the incision line was

cleansed, on-sterile dressing applied, darco splint applied]. [Patient advised not to get the incision line

wet after suture removal until the following day. This will allow the tiny sutures sites to seal before

exposure].The patient is encouraged to [remain in post-op shoe, remain in aircast that was dispensed

today with patient instructions and training provided by staff, remain in aircast dispensed at a previous

visit, get into an accommodating shoe to tolerance, wear normal shoes again]. We will see them in follow-up in [1, 2, 3, 4, 5, 6, 12, 24, prn] weeks’ time or sooner should problems arise.

Post-op Visit Initial Patient: [Patient.Name] Account No: [Patient.AcctNo] Date: [Date]

Subjective: This is a post-surgical visit status post [osseous, soft tissue, toenail] surgery. The patient

admits [no F/C/N/V/CP/SOB/calf pain or tenderness, fever today, fever over the weekend that has

resolved, calf pain out of proportion to surgery]. Patient admits to [uneventful recovery at this point,

moderate pain, severe pain, falling without injury, falling with additional injury, getting dressing wet, removing the dressing].

Objective: The dressings [are dry and intact, are dirty, have strike through bleeding, no longer being

used, were removed by the patient against orders, fell off and the patient re-wrapped]. Incision area is

[unremarkable, well coapting, minimally swollen, ecchymotic consistent with the level of surgical

intervention, erythematous, dehisced]. [Joint ROM is guarded, Joint ROM is favorable, Joint ROM is

limited, Osteotomy sites without crepitation or instability appreciated.] Negative Homan sign, no pain

on medial-lateral or anterior-posterior compression of the calf musculature. Surgical foot appears

[stable relative to level of surgical intervention, edematous more than expected, erythematous, quiescent].

Vitals: [Vitals]

Radiographs: Post-op [2, 3] views [ankle, foot] taken reveal(s) [stable osteotomy site, favorable

hardware placement, movement of osteotomy but correction maintained, movement of the osteotomy

and correction undesirable, ideal correction of the deformity].

Assessment: s/p [bunionectomy,chilectomy,arthrodesis digit, derotational arthroplasty digit, extra

osseous talo tarsal stabilization, arthroplasty, flexor tenotomy, resection exostosis, excision neuroma,

removal retained hardware, excision foreign body, permanent ingrown nail procedure, incision and

drainage procedure, excision Acc navicular deformity, repair posterior tibial tendon partial tear,

endoscopic plantar fasciotomy] [1,2,3,4,5] [right, left]

176

Plan: Status-post corrective/reconstructive surgery [doing well, having complications]. [I removed the

old dressing and performed a sterile dressing change after cleansing the incision line, removed the

sutures, cleansed and dressed, inspected the sutures and they are not yet ready for removal, pulled the

drain from the wound]. The patient was given post-operative instructions for [complete non weight

bearing, partial weight bearing with the use of an aircast, PWB using a post op shoe, full weight bearing

as tolerated]. The patient is to [remain in a protective aircast, remain in a protective post-op shoe

device, move to a comfortable shoe, remain in a below knee fiberglass cast, use knee walker, use

walker, use wheelchair]. The patient was [ordered to perform ROM exercises at a minimum for five

times daily for 10 minutes each time, advised not to get the site wet, instucted to clean and dress the

incision line after showering, return to normal bathing practices]. Follow-up in [3 days, 7 days, 9 days, 11 days, 2 weeks, 3 months, 6 months, 1 year, prn] or sooner should problems arise.

Pre-op Consent

[FirstName] has been advised of the risks versus the benefits and approximate disability involved for the

procedures being considered. In addition, the patient has been advised as to the alternatives of care,

including continued conservative care as well as proposed surgical procedures. The patient understands

that if surgical procedures are performed, there are risks and complications that could occur, including

but not limited to: hematoma formation, seroma formation, development of a DVT or phlebitis,

infection, painful scar tissue formation, limited motion, delayed-union, non-union, mal-union, reaction

to implanted biomaterials, over-correction, under-correction with recurrence of the deformities,

continued pain, and the possibility that future surgery may need to be performed. The patient was

given the opportunity to ask questions which were answered to the best of my ability. The patient

seems to understand these risks. Informed consent forms [were read by the patient, were discussed,

were signed and scanned into the chart, will be prepared and signed at the time of surgery]. The patient

will [consider all these options, elects to proceed with the stated procedures and will schedule accordingly*, desires to take some time to consider the options, seek an additional opinion].

Pre-op Consent

Request and Consent for Operation or Treatment


Operation: I, [Patient.Name], authorize Dr. [User.LastName] to perform or direct the performance of

the following operation/treatment and in doing so to utilize such assistant(s) as may be selected by him/her: [Procedure Name?]

Indications: I understand the reason for this procedure is [Reason?].

Additions: I request and authorize Dr. Baize to perform operations and procedures in addition to or different from those now

177

Contemplated, whether or not arising from presently unforeseen conditions.

Risks: This authorization is given with the understanding that any operation or treatment involves some risks and hazards.

The more common risks include: Infection, Bleeding, Allergic Reactions, Recurrence, Delayed Healing

and Loss of Limb/Amputation, or Life/Death. These risks can be serious.

Alternatives: [Alternatives?]

Anesthesia: The administration of anesthesia also involves risks. I request and consent to the use of such anesthetics as may be considered necessary by the person responsible for these services.

Pathology/Disposal: I consent to the pathological examination under the discretion of Dr. Baize and/or the eventual disposal of any tissues or parts which may be removed.

No Guarantee of Success: I understand that no guarantee or assurance has been made as to the results

of the procedure and that it may not cure the condition. It also may cause a worsening in the condition.

CRPS: I understand that there is a risk associated with any minor or major surgery of contracting chronic

regional pain syndrome. I understand the onset of this syndrome to be increased pain. Due to this

complication, I understand that I must follow all post-operative instructions and report immediately if pain increases because early intervention is imperative.

Patient's Consent: I have requested, read, and fully understand this consent form, and understand I

should not sign this form if all items, including all my questions, have not been explained or answered to

my satisfaction or if I do not understand any of the terms or words contained in this consent form. I

have had sufficient opportunity to discuss my (the patient's) condition and treatment with the physician

and his/her associates.

IF YOU HAVE ANY QUESTIONS AS TO THE RISKS OR HAZARDS OF THE PROPOSED OPERATION OR

TREATMENT, OR ANY QUESTIONS CONCERNING THE PROPOSED OPERATION OR TREATMENT, ASK YOUR

PHYSICIAN NOW BEFORE SIGNING THIS CONSENT FORM. DO NOT SIGN UNLESS YOU HAVE READ AND THOROUGHLY UNDERSTAND THIS FORM.

Physician Declaration: I have explained the contents of this document to the patient and have answered

all the patient's questions and to the best of my knowledge, I feel that the patient has been adequately informed and has consented.

Signed [Long Date] by:

__________________________________________________

[Patient.Name]

178

Pre-op Orders

Pre-Op Orders

Patients Name: [Patient.Name]

Date of Surgery:

Home Phone: [Patient.Phone]

________________________________________________________________________________________

OBTAIN CONSENT FOR:


Medical/Cardiac Clearance Needed: (Medical, Cardiac, None)

PAT (Pre-Admission Testing)

(Y, N) Labs/EKG per Anesthesia Protocol

(Y, N) Pre-Op Lab Studies

(Y, N) UCG

(Y, N) K+

(Y, N) PT/PTT

(Y, N) Other:

Preps and Scrubs

(Y, N) Instruct patient to wash with Antibacterial Soap the night before and the morning of surgery

(Y, N) Have patient wash using betadine scrub (to be purchased by patient)

(Y, N) Chloraprep (provided by surgeon)

(Y, N) Other

179

Day of Admission

(Y, N) NPO per Anesthesia

(Y, N) Shave operative site in holding area per protocol

(Y, N) DVT Protocol

(Y, N) Foot sequential compression device (Ted Hose, thigh high, knee high)

Medications

Pre-op medications and IV according to Anesthesia Protocol

(Y, N) Ancef 1 gram IVPB on call to OR

(Y, N) Ancef 2 grams IVPB on call to OR

(Y, N) Vancomycin 1 gram IVPB

(Y, N) No IV Antibiotic

Other:

Removal of Painful Internal Fixation

Pre-op diagnosis: Painful internal fixation [right, left]


Procedure: removal painful internal fixation device deep


Assistants: none

Anesthesia: local

Hemostasis: epinephrine in local anesthetic


This patient presents for removal of painful internal fixation. Patient states the discomfort is worsening

and limiting daily activities. All risks vs. benefits have been explained in great detail including but not

180

limited to risk of infection, numbness, floppy toe, wound dehiscence, re -occurrence of deformity requiring further surgery. The patient understands these risks and elects to proceed with the procedure.

Procedure:


a half and half mixture of 0.5% Marcaine w/ epi and 1% lidocaine plain in a regional block fashion. The foot was then scrubbed, prepped and draped in the normal sterile fashion.

Attention was directed to the area of the [right, left] foot where a 2 cm linear skin incision was made.

The incision was deepened through subcutaneous tissues care being taken to avoid all vital neural and

vascular structures. All bleeders were ligated or bovied as necessary. The dissection was carried down to

the level of the deep fascia which was incised giving access to the periosteum. This was incised and

reflected away from the bone. The metallic device which identified, and was removed in a typical

technique. [The same procedure was performed on the more proximal pin.] After removal of [1, 2, 3, 4]

[screw(s), pin(s)], the wound was flushed with copious amounts of normal saline solution. The area was

inspected for completion of removal and it was noted to be excellent. The deep fascia was

reapproximated with 3-0 vicryl and the skin was re-approximated with 3-0 nylon in a simple interrupted technique.

A telfa and dry sterile dressing was applied. The patient was placed in a post-op shoe and a follow-up

visit was scheduled. Instructions were given to remain partial weight-bearing in the post op shoe, keep

foot elevated, and to avoid getting the foot wet under any circumstances until the 10 the day.

RTC [1, 2, 3, 4, 5, 6, 7, 14] days.

181

Figure 53 - X-ray of Internal Fixation

Figure 54 - Example of Interval Fixation in place

182

Silver Bunionectomy Pre-op diagnosis: Painful bunion [right, left]


Procedure: Silver bunionectomy [right, left]


Assistants: none

Anesthesia: local

Hemostasis: tourniquet applied for [10, 20, 30, 40, 50, 60] minutes


This patient presents for correction of painful bunion deformity. Patient states the pain is worsening and




Procedure:

Patient was placed on the operating table in the supine position. The foot was anesthetized with 10 mL

of 0.5% Marcaine w/ epi in a Mayo block fashion. The foot was then scrubbed, prepped and draped in

the normal sterile fashion.

Attention was directed to the dorso-medial aspect of the [right, left] 1st MPJ. A 5 cm curvi-linear skin

incision was made over the metatarso-phalangeal joint. The incision was deepened through

subcutaneous tissues care being taken to avoid all vital neural and vascular structures. All bleeders were

ligated or bovied as necessary. Once to the level of the joint capsule a linear capsulotomy was

performed. Capsular and periosteal structures were retracted thus delivering the met head into the

surgical field. The extensor tendon was transected laterally. An osteotome was used to remove the

medial eminence care being taken not to stake the tibial sesamoid. This was [passed from the field,

passed from the field and sent to pathology]. The wound was flushed with copious amounts of normal

saline solution. The area was inspected for completion of bunionectomy and it was noted to be

excellent. The wound was flushed with copious amounts of normal saline solution. The joint was put

183

through a range of motion and it was favorable. The capsule was re-approximated with 3-0 vicryl and the skin was closed with 3-0 nylon in a simple interrupted technique.

A telfa and a lightly compressive dry sterile dressing was applied. The tourniquet was release and a

prompt hyperemic response was noted to all digits of the right foot. The patient was placed in an aircast

and a follow up visit was scheduled. Instructions were given to remain non-weight-bearing, keep foot

elevated, and to avoid getting the foot wet under any circumstances.

RTC [1, 2, 3, 4, 5, 6, 7, 14] days

Figure 55 - Example of Silver Bunionectomy

Correspondence EPAT Customer Satisfaction Survey

I. What was your EPAT treatment for, [Plantar Fasciitis, Peroneal tendonitis]?

II. How would you rate the sensation of the EPAT treatment, 0-10 with zero being very tolerable and 10 being very uncomfortable? [0,1,2,3,4,5,6,7,8,9,10]

III. Did you have your EPAT treatment to avoid receiving injections? [Yes, No]

IV. How effective was the EPAT at treating your problem, 0-10 with 0 being not effective and 10 being very effective? [0,1,2,3,4,5,6,7,8,9,10]

184

V. Is your pain improved at this time? [Yes, No]

VI. How would you rate your overall improvement, 0-10 with 0 being no improvement? [0,1,2,3,4,5,6,7,8,9,10]

VII. If your pain were to return, would you have the EPAT treatment again? [Yes, No]

VIII. Would you recommend treatment to a friend or family member? [Yes, No]

Letter of Medical Necessity

Date: [Date]

[Patient.PrimaryInsurance]

RE: Patient: [Patient.Name] DOB: [Patient.Birthdate]

To Whom It May Concern:

Please let this letter serve as a certificate of medical necessity for CPT code

[L1902,L1906,L1970,L2820,L4350,L4360,L4386,L4396] for date of service [1,2,3,4,5,6,7,8,9,10,11,12]-

[1,2,3,4,5,6,7,8,9,10,11,12,13,14,15,16,17,18,19,20,21,22,23,24,25,26,27,28,29,30,31]-[2007,2008,2009,2010,2011,2012,2013,2014,2015].

This patient was under my care for treatment of a [painful musculoskeletal condition. This device is

necessary to overcome the patient’s compensations and restore a more normal function while

decreasing pain with ambulation, post-operative condition requiring protection for the patient while

maintaining a degree of mobility in the convalescent period]. This device is fitted to the patient and is not sub-standard for its intended purpose.

We ask that you please reimburse under our contract guidelines for this device as it was dispensed in

good faith.

If you have any further questions or need any additional information please contact the billing

department at 850-479-6250 Monday through Friday from 8:30 am - 5:00 pm CST.

185

Thank you,

Paul D. Brooks, DPM

Letter of Medical Necessity - 64455

Date: 3/28/2014



To Whom It May Concern:

Please let this letter serve as a certificate of medical necessity for CPT code 64455 for date of service 2-

19-2014.

This patient is under my care for treatment of a Morton's neuroma of the left second innerspace. I am

injecting the neuroma in staged intervals of two weeks in order to obtain the desired decrease of painful

symptoms. The patient admits to improvement and wishes to continue with this course of treatment.

We ask that you please reimburse under our contract guidelines for these services. If you have any

further questions or need any additional information please contact the billing department at 850-479-6250 Monday through Friday from 8:30 am - 5:00 pm CST.

Thank you,

Paul D. Brooks, DPM

Letter of Medical Necessity - Orthotics or Diabetic Insoles/Shoes

Date: [Date]



186

Please let this letter serve as a certificate of medical necessity for CPT code [L3000,L5000,A5500,A5513]

for date of service [1,2,3,4,5,6,7,8,9,10,11,12]-

[1,2,3,4,5,6,7,8,9,10,11,12,13,14,15,16,17,18,19,20,21,22,23,24,25,26,27,28,29,30,31]-[2007,2008,2009,2010,2011,2012,2013,2014,2015].

This patient was under my care for treatment of a [painful musculoskeletal condition requiring custom

made orthoses. These devices are necessary to overcome the patient’s compensations and restore a

more normal function of the foot while decreasing pain with ambulation, diabetic at risk condition

requiring custom made multi-density plastizote insoles to be fitted to the extra-depth diabetic shoes.

These devices are necessary to protect the patient against the complications associated with their

diabetic condition and allow the patient to maintain a degree of mobility]. These devices are fitted to the patient and are not sub-standard for the intended purpose.

We ask that you please reimburse under our contract guidelines for this device as it was dispensed in

good faith.

If you have any further questions or need any additional information please contact the billing

department at 850-479-6250 Monday through Friday from 8:30 am - 5:00 pm CST.

Thank you,

Paul D. Brooks, DPM

Post-op Instructions

[Location.Name]

[Location.Address]

[Location.City], [Location.State], [Location.Zip]

Phone: [Location.Phone] Fax: [Location.Fax] E-Mail: [Location.EMail]

Post-Operative Instructions


187

A surgical operation has just been performed on your foot and/or ankle to correct a condition that

caused you discomfort. We must now address the recovery and rehabilitation period. You can speed the

healing process by adhering to the following instructions.

Due to the anesthetic you have had today I recommend that you:

Have a responsible adult drive you home and remain with you overnight.

Rest the day of surgery [you may be tired the next day].

Dizziness is not unusual, so take it easy and rest for the majority of the day.

For the next 24 hours, DO NOT:

Drive a vehicle.

Operate hazardous machinery, power tools, appliances, etc.

Make personal or business decisions, or sign legal documents.

Ingest alcohol, tranquilizers, or sleeping pills.

DIET: Begin with clear liquids and light foods such as water, soup, JELL-O, or soda pop and advance to a

normal solid diet if no nausea is present and if your bladder and bowels are moving normally. Continue

good eating habits along with daily supplemental Vitamin and Mineral tablets [Vitamin C and D, Calcium, and Zinc].

WHAT TO EXPECT: Since most surgery involves remodeling the bone and soft tissue [skin, tendons],

your feet/ankles will probably experience some degree of pain and swelling. There will be a long-acting

local anesthetic around the surgical site that will create numbness for several hours after surgery. As this

anesthetic wears off, you will begin to feel some level of discomfort that usually only lasts a few days

after surgery. The area will be sensitive and you may experience tingling or shooting-type pains. All of

these feelings and discomforts will gradually lessen and should be completely gone within a few months.

The exact healing time will vary from patient to patient and depends on your natural healing ability, as well as your adherence to the instructions that follow, and the exact nature of the surgery performed.

BLEEDING: A small amount of blood seepage [size of a silver dollar] on your dressings is normal, is no

cause for concern, and is usually controlled by simply elevating your lower leg and foot. However, if

188

there is active and persistent bleeding even after elevation [BLOOD RUNNING OUT OF YOUR DRESSING OR DRIPPING ONTO THE FLOOR] please call my office at once.

ACTIVITY: Be kind to your foot/ankle and treat yourself to a few days of relaxation and recovery. In

most cases, you will be allowed to walk immediately following surgery, however, it is very important

that you keep this to a minimum. Limit walking to the bare essentials of every-day activities [using the

bathroom, going to the kitchen, answering the phone]. Otherwise, you should be seated in a bed or

reclining chair with your lower leg and foot elevated above your heart. A simple guide is to have your big

toe at eyeball level, which will always be above the level of your heart. Placing two or three pillows

under your lower leg will easily accomplish this goal. Be certain to keep a gentle bend in your knee, and

NOT to cross your legs/feet so that the blood-flow to and from your lower leg and foot will not be

restricted. If you have been dispensed one, use your incentive spirometry [breathing machine] 10x`s per

hour while awake to increase your oxygen level and decrease your chance of pneumonia.

APPLY ICE [A BAG OF CORN OR PEAS WORK BEST] BEHIND YOUR KNEE FOR 10-15 MINUTES OUT OF

EVERY HOUR YOU ARE AWAKE. ICE ON THE FOOT OR ANKLE WILL DO NOTHING, SINCE YOUR DRESSING WILL BE THICK AND BULKY.

BANDAGES: You must keep the dressings clean and dry. Sponge baths work best for daily cleansing, a

taped plastic bag around your leg will leak and get your dressings wet so keep your leg out of direct

water. If this happens, your chance of infection increases dramatically and I want you to try and dry the

dressing with a towel and cool hairdryer, as well as contact my office for further instructions. Under no

circumstances are you to remove any portion of your dressing. It is my responsibility to evaluate and

remove the dressings from your foot and leg when I see you in your scheduled follow -up office visit,

which is usually in one week time from the operation itself but will vary based on the actual surgery performed.

CAST: You must keep the cast and shoe attached to the bottom of the cast clean and dry. Sponge baths

work best for daily cleansing; again, do not tape a plastic bag around your legend attempt to submerse it

as it will leak and get your cast wet. If this happens, your chance of infection increases dramatically and

I want you to stop and contact my office immediately for further instructions. Under no circumstances

are you to remove any portion of your cast or stick anything inside the cast [such as to scratch an itch]

since you may cut yourself and develop an infection. It is my responsibility to evaluate and remove the

cast when I see you in your scheduled follow-up office visit, which is usually in 2-4 weeks’ time from the

operation itself. You should use the crutches or walker [if these have been prescribed to you] at all

times. Avoid hanging the leg down for any period of time since this will cause swelling inside the cast

and an increase in pain that can be difficult to control.

EXTERNAL FIXATION DEVICE: You must keep the dressings and all exposed hardware clean and dry.

Sponge baths work best for daily cleansing; do not tape a plastic bag around your leg in an attempt to

189

keep it dry as it will leak and get your dressings and wires wet. If this happens, your chance of infection

increases dramatically and you should contact my office immediately for further instructions. Under no

circumstances are you to remove any portion of your dressings, tamper or attempt to adjust your

exposed hardware in any way. It is my responsibility to evaluate and remove the dressings from your

foot and leg when I see you in your scheduled follow-up office visit, which is usually in 1 weeks’ time

from the operation itself.

MEDICATION: It is important to take the medication prescribed for you as directed. This will usually

include a mild narcotic (pain pill), anti-inflammatory, muscle relaxant, antibiotic, and blood thinner. The specific medications will be tailored to your surgical procedure, activities, medical health, etc.

FOLLOW-UP APPOINTMENT: Make sure that you keep all appointments at my office since it is very

important that your recovery be monitored closely. During the rehabilitative stage, all discomforts

should gradually disappear and you will be ready to experience the results of our combined efforts. In

the meantime, if you feel uncertain about the progress of your healing or observe an unusual condition, please call the office at the number(s) below for further instruction(s).

Severe pain following surgery is rare, however, if severe pain occurs and is uncontrolled by the

medication prescribed for you, please call my office. While recovering, it is advised that you do not use

any hot water bottles or heating pads and that you avoid alcohol when taking prescription medications,

unless instructed otherwise. Your first post-operative appointment in my office is [Enter appointment Date and Time].


_________________________________________

[Patient.Name]

_________________________________________

[User.Name], [User.Initials]

Post-op Instructions - Matrixectomy

[Location.Name]

[Location.Address]


190


Post-Operative Instructions for Chemical Matrixectomy & Nail Procedures


Watch for signs of infections i.e. pain, redness, swelling, pus, red streaking up your foot and or leg, fever

or chills. If you should develop any of the above, call Dr. [User.LastName] immediately at

[Location.Phone] and tell the person answering the phone that you recently had surgery and need to talk with Dr. [User.LastName].

24-48 hours after surgery remove bandages and bathe as normal. Scrub the surgical site with soap and

water. Dry the area and apply Amerigel® to the operative site and cover with accommodative dressings.

Your toe will be numb for approximately 4 to 5 hours. Begin taking extra-strength Tylenol; Advil; or the

prescription written by the Dr. Take the prescription for the first few days whether you have pain or

not. Follow the instructions on the label on the bottle. If this does not help with the pain, you may want

to call the office at [Location.Phone]. If it is after hours Dr. [User.LastName] will be paged.


_______________________________________

[Patient.FirstName] [Patient.LastName]

_______________________________________

[User.FirstName] [User.LastName], [User.Title]

191

Post-op Instructions - Verruca

[Location.Name]

[Location.Address]



Post-Operative Instructions for Verruca Excision


Watch for signs of infections such as pain, redness, swelling, pus, red streaking up your foot and or leg,

fever or chills. If you should develop any of the above, call Dr. [User.LastName] immediately at

[Location.Phone] and tell the person answering the phone that you recently had surgery and need to talk with the Doctor.

24-48 hours after surgery remove bandages and bath as normal. Scrub the surgical site with soap and

water. Dry the area and apply Amerigel® to the operative site and cover with accommodative dressings.

The operative site MAY be numb for approximately 4 to 5 hours. Begin taking extra-strength Tylenol;

Advil; or the prescription written by your doctor. Take the prescription for the first few days whether

you have pain or not. Follow the instructions on the label on the bottle. If this does not help with the

pain, you may want to call the office at [Location.Phone]. If it is after hours Dr. [User.LastName] will be paged.


_______________________________________

[Patient.FirstName] [Patient.LastName]

_______________________________________

[User.FirstName] [User.LastName], [User.Title]

192

Durable Medical Equipment AFO Prescription - Casting

At this time an [Arizona, Richie] style, custom ankle foot orthosis was prescribed for [right, left, bilateral]

foot and ankle. It is expected that the patient will require the use of this device for an extended period

of time and this device has been utilized in an attempt to prevent the need for surgery. Goals of this

device are to [reduce ambulatory pain, improve instability and subtalar joint function, limit further

progression of the patient's condition, improve stability, reduce hind foot valgus, protect atrophy of skin

and soft tissues]. The AFO is made from a mold of the patient’s foot and ankle. The severity of the

deformity and instability requires custom molding to achieve the desired clinical results. The pat ient was

casted partially weight bearing in a biomechanically neutral position of the foot and ankle. I explained

to the patient that the device will fit and function best in a lace-up shoe with stiff heel contour. The

patient was cautioned to not purchase any new shoes until device is dispensed to them to ensure

proper fit. They will return to the office when the device has returned from the lab for dispensing and fitting.

AFO Prescription - Mini-templates

At this time a double upright, hinged [fixed, temporarily fixed] ankle joint, custom ankle foot orthotic

devices with biomechanical functional foot pad was prescribed for the [right, left, bilateral] foot and

ankle due to the amount of hind foot valgus present and posterior tibial tendon dysfunction p resent.

The custom device was chosen versus a pre-fabricated device not tolerated or beneficial to the patient.

It is expected that the patient will require the use of the ankle foot orthosis for an extended period of

time. The custom ankle foot orthosis is utilized in an attempt to reduce the need for surgery. Goals of

the therapy are: 1.) Reduce ambulatory pain. 2.) Improve subtalar joint function. 3.) Limit further

progression of the patient's condition. 4.) Improve stability. 5.) Reduce hind foot valgus. The patient

was casted in biomechanically neutral position of the foot and ankle. I explained to the patient that the

device will fit and function best in a lace-up shoe with stiff heel contour. The patient was cautioned to

not purchase any new shoes until the device is dispensed to them to ensure proper fit. Patient will return to the office when the device has returned from the lab for dispensing and fitting.

AFO Dispensing


Subjective: Patient presents this visit for dispensing of custom molded, fully functional AFO appliance to

treat their symptomatic [right, left, bilateral] [foot, ankle, lower limb] condition. Patient relates no

significant improvement since the last visit with the prior conservative treatment methods, although

they have continued to perform them as instructed at their last visitation documented above.

Physical Exam: Intact neurovascular status bilateral extremities, unchanged since last visit.

193

Dermatological: no erythema, edema, ecchymosis open lesions or signs of bacterial or fungal infection evident at this time.

Musculoskeletal: unchanged since last visit with persistent pain to symptomatic [right, left, bilateral]

lower extremity. The custom molded, fully functional AFO fit well to both their feet and shoe gear

bilateral. In-office gait evaluation and prolonged ambulation reveal no significant sites of irritation with improvement in the symptomatology and gait appreciated.

Impression: Adequate fit of AFO device for treatment of [right, left, bilateral] [plantar fasciitis, ankle sprain, ankle instability, gastrocnemius equinus]

Treatment: I have dispensed the AFO device and fit them to their shoe gear providing explicit oral and

written break-in instructions which should take approximately two weeks’ time frame. They will

continue with all other concomitant conservative care rendered. We will see them back in 3-4 weeks or

sooner should problems arise.

AFO – Follow-up


Subjective: Patient presents at this visit for follow-up of custom molded, fully functional AFO dispensed

several weeks ago to treat a symptomatic [right, left, bilateral] [foot, ankle, lower limb] condition. The

patient relates significant improvement since the last visit, and is continuing to perform the prior

conservative treatment methods discussed, as documented above.

Physical Exam: Intact neurovascular status bilateral lower extremities unchanged since last visitation.

Dermatological: No signs of any AFO-induced irritation evident at this time. No erythema, edema, ecchymosis open lesions or signs of bacterial or fungal infection evident at this time.

Musculoskeletal: The previously symptomatic regions are non-tender to the touch or with full weight

bearing and range of motion. The custom molded, fully functional AFO is in excellent repair and

continue to fit well to both their foot and shoe gear. In-office gait evaluation and prolonged ambulation reveals continued improvement in the symptomatology and gait.

Impression: Improved [plantar fasciitis, ankle sprain, ankle instability, gastrocnemius equinus] with AFO use.

194

Treatment: I have recommended continued use of the AFO on an indefinite basis since the patient has

achieved such marked reduction in the symptomatology over the relatively short time of AFO use. The

patient will continue with all other concomitant conservative care rendered. Patient will return to clinic on an as needed basis or sooner should problems arise.

Aircast Ankle Brace

A [right, left, bilateral] pre-fabricated Ankle-Foot Orthosis, Multi-ligamentous ankle support was

dispensed and fitted at this visit. Due to the patient's diagnosis and related symptoms this is medically

necessary for the treatment. The function of this device is to restrict and limit motion and provide

stabilization in the affected area. The goals and function of this device was explained in detail to the

patient. Upon gait analysis, the device appeared to be fitting well and the patient states that the device

is comfortable at this time. The patient was shown how to properly apply, wear, and care for the

device. The patient was able to apply properly and ambulate without distress. At that time, the device

was dispensed, it was suitable for the condition and was not substandard. No guarantees were given

and the precautions were reviewed. Written instructions and warranty information was given along

with the list of the twenty-one (21) Durable Medical Equipment Supplier Guidelines. All questions were

answered.

Figure 56 - Aircast® Airsport™ Ankle Brace

195

Ankle Brace

An [right, left, bilateral] pre-fabricated [Ankle-Foot Orthosis, Ankle Gauntlet] was dispensed and fitted at

this visit. Due to the patient's diagnosis and related symptoms this is medically necessary for the

treatment. The function of this device is to restrict and limit motion and provide stabilization and

compression to the affected area. The goals and function of this device was explained in detail to the


is comfortable at this time. The patient was shown how to properly apply, wear, and care for the

device. The patient was able to apply properly and ambulate without distress. At that time, the device

was dispensed, it was suitable for the patient's condition and was not substandard. No guarantees were

given and the precautions were reviewed. Written instructions and warranty information was given

along with the list of the twenty-one (21) Durable Medical Equipment Supplier Guidelines. All questions were answered satisfactorily.

[L1902]

Figure 57 - DonJoy® RocketSoc™ Ankle Support Brace

196

Dispensing Orthotics


Custom orthotics were dispensed to the patient today. Due to the diagnosis indicated and related

symptoms, this is medically necessary for treatment. The goals and function of this device were

explained in detail to the patient. Upon gait analysis, the devices appeared to be fitting well and the

patient stated that the devices were comfortable at this time. Home care instructions as well as proper

use and care were explained in detail. No guarantees were given and precautions were

reviewed. [patient.HeShe] was given and warranty information. [patient.HeShe] was advised to break-

in the devices slowly over the course of the next 3-4 weeks starting at one to two hours the first day and

increasing daily according to tolerance and comfort levels.[patient.HeShe] was instructed to call the

office if [patient.heshe] notices any signs of irritation including redness, blistering, or callus

formation. [patient.HeShe] was reappointed in 4 weeks for follow-up evaluation of not only her

orthotics but also the condition for which she is currently being treated.

Durable Medical Equipment Prescription

Durable Medical Equipment Prescription Form

Patient: [Patient.Name] Account No: [Patient.AcctNo] Patient Phone: [Patient.Phone] Age: [Patient.Age]

Medicare No: [Medicare No?] Other Insurance: [Other Insurance?]

Diagnosis: [Previous Amputation, Pre-ulcer callous, Peripheral neuropathy callous formation, Previous

ulceration, Foot deformity, Peripheral Vascular Disease]

Prescription: [Diabetic Extra Depth Shoes, Custom molded shoes, Custom orthotics, Roller Rocker

Bottom Sole or Bar, Sole or Heel Wedge, Tri-laminate inserts, Inserts, Offset Heel, Rigid Rocker Bottom

Sole or Bar, Metatarsal Bar]

Orthoses: [Left, Right]

Shoe Modification: [Left, Right]

What was done: [Heat molding, Dispensed generic Pedor inserts]

Initial patient reaction: [Tolerated with no real perceptible change, Tolerated with better purchase balance and cushioning, Desires a change in style or size of shoe/inlay]

197

Figure 58 - Examples of Durable Medical Equipment

Leg Cast


The patient presented today for the application of a well-padded [short, long] leg [fiberglass*, plaster]

cast to the [right, left] leg. This is the [initial, second, third, fourth, fifth] cast being applied. [He, She] is

being treated for [fracture, sprain, injury, post-op management, wound management] to the [right, left]

[foot, ankle, leg]. No problems or major changes are reported since the patient's most recent evaluation

for this condition. All boney prominences were protected with ample cast padding. The foot was placed

at a [90 degree, slightly plantarflexed, relaxed] angle to the leg. The patient was instructed to remain

[non-weightbearing, partially weightbearing, and to use crutches, and to use a walker, and to use a roll-

about device] at all times until further notice. [He, She] was advised to keep the cast dry. [He, She} was

198

advised to notify the office immediately if the cast is found to be too tight, constrictive, painful, or

defective in any way and to return for evaluation, modification or cast replacement as necessary. The

patient was reappointed for [1 week, 2 weeks, 3 weeks, 4 weeks]. [He, She] will likely [need, not need]

additional casts applied in order to achieve complete resolution of the [fracture, wound, sprain, injury, surgical condition] being treated.

Figure 59 - Leg Cast on Left Foot

Night Splint

A plastic pre-fabricated [right, left, bilateral] static Ankle-Foot Orthosis was dispensed and fitted at this

visit. The device will be utilized for the next six to eight weeks. Due to the severe pain in the heel when

first weight bearing and throughout the day, with diagnosis of [plantar fasciitis, Achilles tendonitis,

plantar fasciitis and Achilles tendonitis] and related symptoms, this is medically necessary for the

treatment. The function of this device is to serve as an anti-contracture device of the plantar fascia and

Achilles tendon and to restrict and limit motion and help reduce excessive stress and strain to the

plantar fascia and Achilles' tendon. It is being utilized to prevent the plantar contracture of the Achilles

tendon and its distal terminus, the plantar fascia, and serve to decrease the stress of the fibers of the

Achilles tendon insertional effect of tension in the proximal fibers of the plantar fascia via its periosteal

attachment. The goals of this therapy are to: 1.) To reduce the pain and symptoms of post-static

dyskinesia. 2.) Prevent non-weightbearing contracture of the Achilles tendon. 3.) Provide static stretch

of the Achilles tendon. 4.) Reduce plantar fasciitis. The goals and function of this device was explained

in detail to the patient. The patient states that the device is comfortable when applied at this time. The

patient was shown and told in detail how to properly wear and care for the device. The patient was able

to apply the device properly and to ambulate without distress. The device was then dispensed and was

suitable for the condition and not substandard. No guarantees were given and precautions were

199

reviewed. Written instructions and warranty information was given along with the list of the twenty-one (21) Durable Medical Equipment Supplier Guidelines. All questions were answered.

Figure 60 - DeRoyal® Night Splint

Non-pneumatic Walker

A [right, left, bilateral] pre-fabricated Non-pneumatic Ankle-Foot Orthosis (Bledsoe LC Boot) was

dispensed and applied at this visit. Due to the patient's diagnosis and related symptoms this is medically

necessary for treatment. The function of this device is to restrict and limit motion, provide stabilization

and immobilization to the affected area. The goals and function of this device was explained in detail to

the patient. Upon gait analysis, the device appeared to fit well and the patient states that the device

was comfortable. The patient was shown and told in detail how to properly wear and care for the

device. They were able to apply the device properly themselves and ambulate without distress. At the

time the device was dispensed, it was suitable for the condition and not substandard. No guarantees

were given and precautions were reviewed. Written instructions and warranty information was given along with the list of the 21 Durable Medical Equipment Supplier Guidelines.

200

Figure 61 - Aircast® Walking Boot

Non-pneumatic Walker for Bunion

A [right, left, bilateral] pre-fabricated Non-pneumatic Ankle-Foot Orthosis (Bledsoe LC Boot) was

dispensed and applied at this visit. Due to the diagnosis of bunion deformity, with correction by

removal of bunion and metatarsal osteotomy, this is medically necessary for the post-operative course

of treatment and to help reduce possible post-operative complications related to the surgery. The

function of this device is to restrict and limit motion of the joint and effect of the long extensors and

flexors as they cross the joint and provide stabilization and immobilization across the first

metatarsophangeal joint. The goals and function of this device was explained in detail to the


is comfortable at this time. The patient was shown and told in detail how to properly wear and care for

the device. The patient was able to apply the device properly and ambulate without distress. At the

time the device was dispensed it was suitable for the condition and not substandard. No guarantees

were given and precautions were reviewed. Written instructions and warranty information was given

along with the list of the twenty-one (21) Durable Medical Equipment Supplier Guidelines. All questions were answered.

[L4386]

Orthotic Casting

I have recommended continued use of current treatment along with the addition of a custom [ orthotic,

hinged ankle-foot orthotic, Arizona style ankle foot orthotic]. The appliance will be used to [control the

hindfoot and forefoot motion, cushion the heel, provide for a slight heel lift effect, completely restrict

motion, restrict motion in only isolated planes]. After obtaining appropriate range of motion

measurements of the hindfoot to forefoot relationship which is documented in the orthotic fabrication

form, using [4 strips of plaster per foot, a foam impression box, a semi weight bearing fiberglass sock]

201

the [right foot, left foot, both feet] were then casted for negative impressions necessary for fabrication

of a model of the feet to create functional orthotic appliances/foot inserts. These functional foot

orthotics/foot inserts will be packaged, handled, and mailed to an outside laboratory and fashioned as

removable devices with appropriate longitudinal arch support and metatarsal balancing as indicated by

the symptomatic deformity. After careful review of symptoms, past treatments, and biomechanical

measurements, it was determined that custom made appliances are indicated for further treatment of patient's condition. Will call the patient when the order arrives.

Figure 62 - Example of Clay Casting

Figure 63 - Example of plaster casting

202

Orthotic Follow-up


Subjective: Patient presents at this visit for follow-up of custom molded, fully functional orthotic

appliances which were dispensed several weeks ago to treat symptomatic [foot, ankle, lower limb]

conditions. Patient relates [significant, no significant] improvement since last visit. Patient [has, has not] continued to perform the prior conservative treatment methods discussed as documented above.

Objective: Intact neurovascular status to bilateral lower extremities, unchanged since last visit.

Dermatological: No signs of any orthosis-induced irritation evident at this time on either foot. No

erythema, edema, ecchymosis, open lesions or signs of bacterial or fungal infection evident at this time.

Musculoskeletal: The previously symptomatic regions are [still painful, but reduced, unchanged,

worsened, resolved] to the touch or on full weightbearing and range of motion. The custom molded,

fully functional orthoses remain in excellent condition and continue to fit well to both feet and shoe

gear bilaterally. In-office gait evaluation and prolonged ambulation reveals continued improvement of

symptomatology and gait.

Assessment: [Assessment?]

Plan: I have recommended the patient continue to use the orthotic appliances on an indefinite basis. I

explained that maximum benefit from orthoses can only be realized with consistent long-term use.

[Since there has been marked reduction in symptomatology,Since there has been limited improvement

in symptoms] I recommended continued use of the orthotics long-term to achieve maximal benefit.

They will continue with all other concomitant conservative care recommended. We will see them back [1 week,2 weeks,3 weeks,4 weeks,6 weeks,3 months,prn] for recheck or sooner should problems arise.

203

Figure 64 - Examples of Orthotics

Figure 65 - Before and After of Orthotics

204

Diabetic Diabetic Neurological and Vascular Exam


Chief Complaint: Patient presents for diabetic examination. Presently [needing a diabetic education and

evaluation, c/o painful elongated painful toenails, c/o new ulceration, c/o old ulceration, c/o ingrown

toenail, c/o abscessed toenail, c/o numb feeling in feet, c/o pain in feet, c/o cold feet, c/o skin changes

on feet, c/o cramps in legs, needing evaluation for and measurement for diabetic shoes, c/o digital

deformities, c/o callouses, c/o malposition of feet, c/o nothing in regards to the foot nor ankle but

advised by primary Care physician to seek regular visits to podiatry as a preventative measure, difficulty sleeping]. Last seen their [PCP,endocrinologist] [Patient.PrimaryPhysician] [Patient.DateLastSeen].


Medications: [Meds]




ROS:

Eyes: [Eyes]

GI: [GI]

GU: [GU]








205

Physical Exam: The patient [well-nourished and well-groomed, NAD, poorly groomed, neglecting of health, has odor of cigarettes]. [Vitals] Most recent blood sugar/A1c:

Vascular: Dorsalis pedis are graded at [0/4R, 1/4R, 2/4R, 3/4R, 4/4R, 0/4L, 1/4L, 2/4L, 3/4L, 4/4L,

dopplerable on the right, dopplerable on the left, non-dopplerable on the right, non-dopplerable on the

left]. Posterior tibial pulses are graded at [0/4R, 1/4R, 2/4R, 3/4R, 4/4R, 0/4L, 1/4L, 2/4L, 3/4L, 4/4L,

dopplerable on the right, dopplerable on the left, non-dopplerable on the right, non-dopplerable on the

left]. Digital hair growth on the toes is [present, sparse, absent]. CFT with the leg elevated was [less than

3 seconds, 3 seconds, more than 3 seconds] at the distal toes bilateral. There [is, is no] evidence of

ischemic skin changes. Temperature from the tibia to the toes is [warm, cool, cold] at anterior tibia to

[warm, cool, cold] at the distal digits bilateral. Lower extremity edema is [not present, 1+, 2+, 3+, 4+, late stage with a brawny appearance, champagne bottle appearance].

Neurological: Balance and coordination [WNL, guarded, analgic, difficulty sitting or standing]. Epicritic

sensation, as measured with a 5.07 Semmes Weinstein Monofilament is [intact, diminished, absent] of

the toes, plantar foot forefoot, plantar arch, heel, and dorsum in [1, 2, 3, 4, 5, 6, 7, 8] out of 8 areas

right foot and in [1, 2, 3, 4, 5, 6, 7, 8] out of 8 areas left foot. Vibratory sensation as measured with a

128Hz tuning fork is [intact, diminished compared to the hand by 2 seconds, diminished compared to

the hand by 4 seconds, diminished compared to the hand by 6 seconds, diminished compared to the

hand by 8 seconds, diminished compared to the hand by 10 seconds or more, absent]. [Clonus is

present.]

Dermatological: Skin is [of normal turgor and temperature, cool and dry, sweaty, thin and atrophic].

Erythema is [not present, present at the hallux, 2nd digit, 3rd digit, 4th digit, 5th digit, plantar aspect of

heel, dorsal aspect] of the [bilateral, right, left] foot. At risk areas are [not present, present due to digital

deformities, present due to bunion deformities, present due to calloused areas susceptible to

ulceration, present due to vascular disease, present due to neurological disease]. [Pre-ulcerative areas are present.] Open ulcerations are [absent, present].

Musculoskeletal: Patient is [able to walk, able to walk with a walker, walking with a cane, able to walk

with assistance, in a wheelchair]. Foot architecture: [Stable foot posture without obvious structural

deformities noted bilateral, Forefoot and digital deformities present, Mid foot deformity present,

Rearfoot malposition and/or deformity present, Ankle malposition and /or deformity present, Digital

amputation present, Ray amputation present, Transmetatarsal amputation present, Below knee

amputation present, Above knee amputation present]. Muscle strength of the lower extremity shows

[normal tone and strength considering age, weak dorsiflexor, weak plantarflexors, weak pronators, weak

supinators]. [Fluid range of motion for all joints from the ankle distal without crepitation noted bilateral,

Range of motion of joints is limited].

Assessment: [Diabetes Mellitus w/o complications, Diabetes Mellitus w/ vascular complications,

Diabetes Mellitus w/ neurological complications, hallux valgus, contracted digits, callouses,

onychomycosis, onychogryphosis, tinea pedis, edema, osteoarthritis, metatrsal head deformity, Diabetic ulceration, critical limb or part ischemia]

206

Plan:

Performed a complete Diabetic examination of both feet and ankles. Diabetes education was provided

to the patient emphasizing the need for proper shoe gear and daily hygiene, daily inspection, early

intervention for foot problems, avoidance of self-care, and the need to maintain the recommended

timeframe between at-risk foot care appointments to reduce the likelihood of developing potentially

serious foot problems. The patient was advised to RTC immediately if any acute foot problems arise no matter how insignificant they may seem to the patient.

Debridement of [non-dystrophic,dystrophic,mycotic*,gryphotic,hypertrophic,lytic,ingrown] toenails in

length and thickness [1-5,6-10] by way of an electric grinder to as close to normal thickness as the

patient would tolerate with good relief obtained as evidenced by pain-free ambulation. Antifungal and

antiseptic applied the nails. The treatment of the toenails is necessary due to patient's [Diabetic*,

compromised peripheral vascular disease, neuropathic disease, renal disease, blood coagulation disease

requiring a blood thinner, severe condition of the nails]. Not performing debridement could result in

medical complications including infection, ulceration and amputation secondary to patient's current medical conditions. [Debridement of callouses.]

Patient instructed to [apply AF nail oil to the infected nails, apply Naftin® gel 1%,apply naftin cream

2%,apply naftin cream 1%, apply urea 10%,apply urea 40%,moisturizing lotion to the feet at home, use prescription products] to all affected areas.

At home care was discussed including daily inspection of the plantar feet and evaluation of fluid stains on socks and shoe gear.

Upon footwear evaluation my suggestions: [continue with current shoe gear, purchase new shoes,

patient to be measured for new diabetic shoes and plastizote inserts, addition of new insoles within

patient's existing shoes]. The following risk factors are present necessitating diabetic extra depth shoes

and plastizote insoles: [no risk factors are present, diabetes with vascular compromise, diabetes with

neurological disease with evidence of callous formation, history of a pre-ulcerative callous, previous

amputation or partial amputation of foot, digital contractures and /or bunion deformities, midfoot contracture, rearfoot contracture, other musculoskeletal foot deformity].

Time spent on education for diabetes mellitus and its effects on the feet and other general areas of the body.

Patient is to return to office in [prn,6 weeks,10 weeks,12 weeks,6 months,1 year], or sooner if problems

arise or condition worsens.

[EXAMINING PHYSICIAN SIGNATURE]

Signature: ____________________________________________

207

Print Name: ____________________________________________

Date: ____________________________________________

[PRIMARY CARE PHYSICIAN SIGNATURE]

Signature: ____________________________________________

(I certify by signing this document that I have reviewed the above diagnosis(es) and agree with the

findings. I am including a copy of this diagnosis in the patients' chart.)

Print Name: ____________________________________________

Date: ____________________________________________

Diabetic Shoe Dispensal Patient: [Patient.Name] Account No: [Patient.AcctNo] Date: [Date]

DOCUMENTATION of IN-PERSON FITTING AND DISPENSING

Patient is here for dispensal of diabetic shoes and inserts. Pt was dispensed [1, 2] individual A5500 shoes

and [3, 6] individual [A5512, A5513] inserts. The inserts were [heat molded, custom molded with a

biofoam impression to be a total contact device and evaluated] to patients feet and dispensed. The DME

is Medicare certified equipment that was purchased through Dr. Comfort. The inserts are a multi -density plastizote of specific durometer.

Patient wore shoes and was satisfied with the fit and comfort. Pt was also satisfied with the aesthetic

appearance of shoes. Pt was advised to return to the office if any sites of irritation arise, or to call if there happen to be any podiatric questions.

Patient was given instruction as to the break-in procedures and warranty information for the Dr.

Comfort shoes and signed receipt of the above items. Office staff has disclosed the CMS Medicare

DMEPOS supplier standards.

Patient to follow up in 2 months if no other problems arise between now and next visit.

208

Figure 66 - Display of Diabetic Shoes

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