Podiatry Note Templates

PODIATRIC Brooks Foot & Ankle
Associates
PRACTICE Medicine and Surgery of the
Foot and Ankle
TEMPLATES
BRADIE BRITT 2201 E Nine Mile Rd Pensacola, FL 32514
JESSICA VERVOORT Telephone : 850-479-6250
KENNETH OMS Fax : 850-479-6247
SUZANNE JEAN-BAPTISTE Email : info@FeetAreNeat.com
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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
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 we ll 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

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]
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 bil ateral. 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 asymp tomatic 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:
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 th eir
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]
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]
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

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]
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 p adding 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]
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
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
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

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
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 patie nt [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

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 the y 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
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]
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
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
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

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.
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 phy sical 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

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
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
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
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

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*].
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[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
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
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
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
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

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]
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
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
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
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,
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, complication s, 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

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

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
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].
Plan: I have discussed the treatment options once again with the pati ent and have recommended
[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

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]

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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.
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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

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,
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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.
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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]

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Figure 30 –Photograph and X-ray of Hallux Rigidus deformity
Hallux Rigidus – Follow-up - Steroid Injection

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].
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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.
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Figure 32 – Hallux Valgus of the Left Foot
Hammertoe - Initial Visit

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,
Medications: [Meds]

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Review of Systems:
ENMT: [ENMT]
GI: [GI]
GU: [GU]
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
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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 mul ti-
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].
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Figure 33 – Before and After Demonstration of Hammertoe Surgery
Hammertoe - Initial Visit - Arthroplasty

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

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

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Hammertoe – Follow-up
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
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.
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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

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Osteoarthritis - Initial Visit

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]
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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
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.
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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
[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:
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ENMT: [ENMT]
GI: [GI]
GU: [GU]
Dermatological: There is [ecchymosis, erythema, edema, heat, pain to palpation] of the affected area.
position unassisted. Percussion of the tarsal tunnel and porta pedis [negative, positive] for Tinnel's or
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.
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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
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]
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
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

[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
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

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

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.
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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

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.]
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Figure 43 – Plantar Fasciitis Surgery
Plantar Fibroma
[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
(< 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

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
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

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
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
capillary fill time is <5 seconds bilateral. There are no ischemic skin changes evident bilateral lower
extremities.
extremity and foot bilateral. The patient can heel and toe walk with ease as well as arise from a s eated
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

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

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.
fill time is [immediate, delayed] bilateral. There are no ischemic skin changes evident bilateral l ower
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

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.
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
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

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

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
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

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,
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.
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
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

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
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

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
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

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

146
Neuroma Discharge
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]

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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
148
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

149
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

150
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
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
RTC [1, 2, 3, 4, 5, 6, 7, 14] days.
Biopsy epidermal Nerve density

Epidermal Nerve Fiber Density Biopsy

152
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
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 us ed 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
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.
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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 pro cedure.
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:
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.
Procedure:
Patient was placed on the operating table in the supine position. The foot was anes thetized with 3mL of
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
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.

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.

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

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 ex ercises 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
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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.
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 sub merse 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
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 w ell 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

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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PODIATRIC Brooks Foot & Ankle

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

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

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

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

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

Dr. [User. Name]

Figure 1 - Benign Neoplasm on Left

Dermatitis - Established Patient - Biopsy - AFC

Past Medical History: [PMH]

Past Surgical History: [PSH]

Past Family and Social History: [PFSH]

Plan: [99202] [11100]

Dermatological Exam Normal

Foreign Body Health & Physical

Family History: [Family History]

Social History: [Social History]

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

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

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

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

X-rays taken and reviewed

I&D of foreign body

Figure 3 - Screw Foot and Flip-Flop Sandal

Past Medical History: [PMH]

Past Surgical History: [PSH]

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

PMH, PSH, Medications: Unchanged since last visit.

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

Incision & Drainage – Established Patient

Constitutional symptoms: [Constitutional]

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

Incision & Drainage –New Patient

Past Medical History: [PMH]

Past Surgical History: [PSH]

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

Ingrown Nail – Follow-up

Figure 4 - Healing Progression of Postoperative Ingrown Toenail

PMH, PSH, Medications: Unchanged since last visit.

Figure 5 - Soft Kissing Corn

Nail Avulsion - Initial

Past Medical History: [PMH]

Past Surgical History: [PSH]

Family History: [Family History]

Social History: [Social History]

Constitutional symptoms: [Constitutional]

Ears, Nose, Mouth, Throat: [ENMT]

Nail Avulsion - Follow-up

Onychomycosis - Established Patient

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

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

Figure 6 - Proximal subungual onychomycosis (arrow)

Onychomycosis - New Patient

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

Past Medical History: [PMH]

Past Surgical History: [PSH]

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

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

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

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

Phenol and Alcohol Matrixectomy

Phenol and Alcohol Matrixectomy – Established Patient

Constitutional symptoms: [Constitutional]

Phenol and Alcohol Matrixectomy – New Patient