CLINICAL SKILLS EVALUATION

PATIENT NOTE

HISTORY: Describe the history you just obtained from this patient. Include only information
(pertinent positives and negatives) relevant to this patient's problem(s).
Will Foreman is a 31 yo M who came in for the evaluation of heel pain for the past 2 weeks following
a marathon preparation. Pain was localized on the R heel, rated at 7/10, stretching or tearing in
character, radiating to the arc of the foot, intermittent, worse in the AM upon first few steps, relieved
by exercise, ice and IBU prn, ad worsened by walking and sitting for prolong period of time. No
noted stiffness, fever, HA, back pain, joint pain elsewhere, cough, isect bite, trauma, rash,
photosensitivity, and Raynaud phenomenon. No history of trauma to the foot.
ROS: none except above
PMH: no bone, muscle and joint disorder; no DM
All: nka
Meds: ibuprofen, prn
PSHx: none
FH: father with arthritis, mother healthy
SH: accountant, married and sexually active with wife x 10 yrs; no weight loss, decreased appetite,
illicit drug use and tobacco use; drinks alcohol, no recent travel; runner, denies red meat and seafood
diet

PHYSICAL EXAMINATION: Describe any positive and negative findings relevant to this patient's
problem(s). Be careful to include only those parts of examination you performed in this encounter.
VS: 125/80; T 99F; R 14; HR; 69
GS: sitting comfortably, nad
M/S: no Calluses, deformity, and ulcers; no warmth but with tenderness upon palpation of the heel
and the arc of R foot; positive calcaneal stress test; positive pain with dorsiflexion of the R foot; ROM
intact except dorsiflexion of R foot; neg mulder sign; +2 pulses, intact sensation, M 5/5
Neuro: DTR +2 b/l LE

DATA INTERPRETATION: Based on what you have learned from the history and the physical
examination , list up to 3 diagnoses that might explain this patient's complaint(s). List your diagnoses
from most to least likely. For some cases, fewer than 3 diagnoses will be appropriate. Then, enter the
positive or negative findings from the history and the physical examination (if present) that support
each diagnosis. Lastly, list initial diagnostic studies (if any) you would order for each listed diagnosis
(e.g. restricted physical exam maneuvers, laboratory tests, imaging, ECG, etc.)

Diagnosis #1: Calcaneal stress fracture

History Finding(s) Physical Exam Finding(s)

marathon runner exercised x 2 weeks preparation tenderness upon palpation of the heel
r heel pain positive calcaneal stress test

Diagnosis #2: Plantar fascitiis

 History Finding(s) Physical Exam Finding(s)
morning pain on first few steps of the R foot tenderness upon palpation of the heel
marathon runner restricted dorsiflexion
r arc foot pain

Diagnosis #3: Retrocalcneal bursitis

History Finding(s) Physical Exam Finding(s)

calcaneal pain R tenderness upon palpation of the heel

Diagnostic Study/Studies
X ray of foot and ankle
Bone scan of foot
MRI of foot