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Podiatric Practice Templates Full_Final Edit

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Podiatric Practice Templates Full_Final Edit

  1. 1. PODIATRIC PRACTICE TEMPLATES Brooks Foot & Ankle Associates Medicine and Surgery of the Foot and Ankle BRADIE BRITT JESSICA VERVOORT KENNETH OMS SUZANNE JEAN-BAPTISTE 2201 E Nine Mile Rd Pensacola, FL 32514 Telephone : 850-479-6250 Fax : 850-479-6247 Email : info@FeetAreNeat.com
  2. 2. 1 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 –NewPatient..................................................................................................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 AvulsedNail.....................................................................................................................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
  3. 3. 2 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-upVisit..............................................................................................................85 Gait Analysis.................................................................................................................................85 Gout - Initial Visit..........................................................................................................................86 Gout - Follow-UpVisit...................................................................................................................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
  4. 4. 3 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 TineaPedis - Initial Visit............................................................................................................... 138 TineaPedis - Follow-up............................................................................................................... 140 Neurology......................................................................................................................................141 Neuroma - Initial Visit................................................................................................................. 141 Neuroma - Follow-up- Steroidinjection....................................................................................... 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
  5. 5. 4 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
  6. 6. 5 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
  7. 7. 6 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 andAfter 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
  8. 8. 7 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
  9. 9. 8 Introduction Group 2 isediting adocumentfora podiatrygroupin PensacolaFlorida.Thisdocumentwillbe usedby the podiatricpractice to expeditetheirpatientrecordkeepingprocess.BrooksFoot& Ankle Associates provideduswiththe templatestheyuse torecordpatientnotes.I visitedthe practice andcopied180 pagesof templatesoutof theirpatientrecordkeepingsoftware,TrakNet.Withthe helpof JoshuaBritt, DPM, an associate of the practice,we were able toremove templateswhichdidnotneedediting. The bracketsthat are usedthroughoutthe documentare neededsothatTrakNetcan create quickfill optionswithinthe program. Dermatology Benign Neoplasm/Lesion of uncertain behavior Patient: [Patient. Name] AccountNo:[Patient. AcctNo] Date:[Date] Subjective:Patientpresentstodayc/oa[painful, non-painful] [lesion, growth,mole, wart, darkspot, hard area, bleedinglesion] onthe [right, left][foot, ankle, leg].The areaof concernislocated[on, between, onthe bottomof, beneath, ontopof, onthe right side of, onthe leftside of, onback of, on frontof] the [the sulcusregion, the heel, the arch, the 1st MTPJ, the 2nd MTPJ, the 3rd MTPJ, the 4th MTPJ, the 5th MTPJ, the bigtoe, the 2nd toe, the 3rd toe, the 4th toe, the 5th toe] [the foot, the ankle, the heel, the leg].She [has, hasnot] noticedrecentchangesinthe area.She [has, doesnothave] a personal historyof skincancer.She [has, hasnot] beenpreviouslydiagnosedwithandtreatedforother formsof cancer.There [isa, isno] known familyhistoryof skincancer. Objective:PMH,PSH,Medications:Unchangedsince lastvisit.The patient'sneurovascularstatusof bilateral lowerextremityisunchangedsince lastvisit. Dermatological:The lesionislocatedonthe [plantar, dorsal, medial, lateral, anterior, posterior] surface of the [right, left] [foot,ankle, leg]. The lesionis[hyperkeratotic, hyperpigmented, hypopigmented, raised, flat, red, blue, black, white, dark, papular, macular, isolated, singular, multilobulated, soft, firm, freelymovable, fixed, intraepidermal, dermal, subcutaneous, deepfascial, osseous,chalky, blanchable, non-blanchable, irregularborders, round,triangular, square, stellate, translucent, smooth, course, with interruptedskinlines, wellcircumscribed, bleeding, crusted, escharotic, nucleated, ulcerated].After inspection/debridementthe lesiondoesnotreveal anyverruca-type tissue,retainedforeignbodies,or cardinal signsof infection. Otherwise,there isnoevidence of edema,erythema,ecchymosis,open lesions,interdigitalmacerationorsignsof bacterial orfungal infectionof bilaterallowerextremities. No varicosities,telangectasias,pigmentedlesionsorsignsof venousstasischangesbilateral lower extremities. [Inadequate, Adequate] fatpaddingtothe inferioraspectof eachfootappreciated. Musculoskeletal:[Pain,Nopain] isnotedtopalpationof the lesion.It[does, doesnot] appeartobe intimatelyassociatedwithabonyprominence orfootdeformity.[Bunion, Hammertoe, Tailor'sbunion, Metatarsal, Tarsal, Rearfoot] deformity[is, isnot] noted.
  10. 10. 9 Assessment: [Benignneoplasm, Deformedmetatarsal, Porokeratomadiscrita, Neoplasmof uncertain behavior, Fibroma, Inclusioncyst, Foreignbodygranuloma, pyogenicgranuloma, verruca, IPK, Blue nevus, Junctional nevus, Basal cell carcinoma, squamouscell carcinoma, possible melanoma] Plan: 1) I have discussedthe treatmentoptionswiththe patientindetail,includingnon-surgical vs.surgical care. Basedon myfindingsI recommended [Non-surgical care, surgical management] of the condition.Irecommended[excisionof the entire lesion, punchbiopsy, shave biopsy, excisionalbiopsy, withhistopathologicidentification.][Destruction of the lesionwith][Serialdebridementandapplicationof Canthecur, liquidnitrogen, off-loading, periodic paringof the lesion, modificationsof shoe inserts, dailyapplicationof aperture pads]. 2) The patientdesires[non-surgical care, surgical management] forthe condition.Treatment today consistedof [paringof the lesionfollowedbythe applicationof Canthecur, destructionof lesionwith liquidnitrogen, palliative off-loading, biopsy, surgical planning,counselingandacomprehensive informedconsentsessionduringwhichthe patientwasaffordedthe opportunitytoaskany questions and all questionswere answeredtothe bestof my ability].[The patientwasadvisedof the potential risksand complicationsassociatedwithexcisionof the lesion.She wasadvisedthataninfectionmay occur, the lesionmayrecur,a painful scarmightdevelop,numbnessandswellingmayoccurand persist, that if the lesionisfoundtobe malignanta referral toan oncologistand/orotherspecialistsmaybe needed,thatadditional surgical andnon-surgical treatmentsmaybe required, annoguaranteeswere givenasto outcome.] 3) Comprehensive oral andwritteninstructionswereprovidedtothe patientforaftercare.She was instructedtoremain[non-weightbearing,partial weightbearing, fullyweightbearing] onthe affected limb.She wasalsoadvisedto[keepthe areadry, keepthe footelevated, totake a few daysoff work, to use OTC Tylenol, Ibuprofen, orAleve forpaincontrol].Patientwasreappointedfor[5days,1 week, 2 weeks, 3weeks,1month,PRN] for follow-up.The patientwasadvisedtocontactthe office immediately if problemsarise. _____________________________ Dr. [User. Name]
  11. 11. 10 Figure 1 - Benign Neoplasm on Left Dermatitis - Established Patient - Biopsy - AFC Patient:[Patient.Name]AccountNo:[Patient.AcctNo] Date:[Date] Subjective: Thisisa [Patient.Age] year-oldpatientwhere [Patient.heshe]presentstodaytothe office witha [new, existing, flareup, reoccurring, postopcomplication] skincomplaintof [hives, pimples, itchiness, inflammation, irritation] ontheir[left, right, bilateral] lowerextremity.Ithasnotrespondedto [topical OTCanti-fungals, dryingagents, footsoaks, and otherconservativetreatmentoptions]. Patient [has, has not] had a similarconditionpreviouslyanddeniesanyrecenttraumaorinciting events. Patient[denies, relates] afamilyhistoryof thiscondition. Allergies: [Allergies] Medications:[Meds] Past Medical History:[PMH] Past Surgical History:[PSH] Past FamilyandSocial History:[PFSH]
  12. 12. 11 Reviewof Systems: GI: [GI] Musculoskeletal: [MSK] Integumentary: [Integumentary] Hematologic/Lymphatic: [Lymphatic] Allergic/Immunologic:[Immunologic Objective: The patientisappropriatelydressed,articulate,awake,alert,andorientedx 3, appears statedage and looksto be in [good*,poor] health. Vascular:Dorsalispedispulsesare [0,1,2*,3,4]/4 left,dorsalispedispulsesare [0,1,2*,3,4]/4right,and posteriortibial pulsesare [0,1,2*,3,4]/4left,posteriortibial pulsesare [0,1,2*,3,4]/4 right.Capillary fillingtime withthe legelevatedis[<5right*, 5 right,>5 right,<5 left*,5 left,>5left] secondsatthe level of the digital tufts.There [is, are no] ischemicskinchangesevidentin[left, right, bilateral*] lower extremities.There [is, isnot*] [edema*,pittingedema+??,non-pittingedema+??] noted lower extremity[left,right, bilateral*].Digital hair[present*, notpresent] Neurological:Epicriticsensationincludingsharp-dull,lighttouch,proprioception,2-pointdiscrimination (< 12 mm at level of hallux tuft),vibration(128MHz tuningfork) andprotective threshold(10.0gram monofilament) are [intact*, diminished] and[with,without*] focal motororsensorydeficit[left, right, bilateral*] lowerextremities. Normal muscle massappreciatedtoboththe lowerextremityandfoot [left, right, bilateral*].[Negative*,Positive] Mulder`ssigntothe interspacesof bothfeet. Dermatological:There isquestionableskinabnormalitynotedon[plantar, dorsal, medial, lateral] [foot, ankle].There [is, isnot] small vesicleformationthroughout.Otherwise,there isnoevidence of edema, ecchymosis,orsignsof bacterial infectionof bilaterallowerextremities. Novaricosities,telangectasias, pigmentedlesionsorsignsof venousstasischangestobilateral lowerextremities. Adequate fatpadding to the inferioraspectof eachfootappreciated. Musculoskeletal:One notesa[rectus*, planus, cavus] foottype with[mild, no] gastroc-soleusequinus deformity.One notes[no*, mild] evidence of limblengthdiscrepancy.Range of motionof the ankle, subtalarand midtarsal joints[are, are not] painfree andwithinnormal limits.There are [no*, some] [flexible semi-rigid, rigid] digital contracturesnoted[1L, 1R,2L, 2R, 3L, 3R, 4L, 4R, 5L, 5R]. Muscle strengthis[1, 2, 3, 4, 5]/5 forall four lowerextremitymusclegroups. Assessment:[692.9] Plan:[99202] [11100] All questionswereansweredindetailandtheyare to returnto office in[one, two] weeks.
  13. 13. 12 Figure 2 – Dermatitis Dermatological Exam Normal Dermatological Exam: There isnoevidence of edema,erythema,ecchymosis,openlesions,interdigital maceration,orsignsof bacterial orfungal infectionbilateral lowerextremities. Novaricosities, telangectasias,pigmentedlesionsorsignsof venousstasischanges bilateral lowerextremities. Foreign Body Health & Physical Chief Complaint:This[patient.Age] yearold[patient.Gender]presentstodaystatingthat[patient.heshe] thinkssomethingisin[patient.hisher] [right, left] foot.Conditionhasbeenpresentfor[1, 2, 3, 4, 5, 6, 7, 8, 9, a few, several] [day, days, week, weeks, month, months, year, years]. Patient[recallssteppingon glass, thinksit’sa woodsplinter, doesnotrecall anytraumato the areaor steppingonanything. Patient relates[pain, tenderness, redness,drainage].Athome,patient[hasbeensoakingarea, didtrytoremove foreignbody, hasnotperformedanyhome care]. Allergies:[Allergies] Meds: [Meds] PMH: [PMH] PSH: [PSH] FamilyHistory:[FamilyHistory]
  14. 14. 13 Social History:[Social History] Immunizations:[Immunizations] Reviewof System: Constitutional:[Constitutional] CV:[CV] Endocrine:[Endocrine] ENMT: [ENMT] Eyes:[Eyes] GI: [GI] GU: [GU] Immunologic:[Immunologic] Integumentary:[Integumentary] Lymphatic:[Lymphatic] MSK: [MSK] Neurological:[Neurological] Psychiatric:[Psychiatric] Respiratory:[Respiratory] Physical Exam: [Vitals] Constitutionalexam: Patientisapleasant,[patient.Age] yearold[patient.Gender],[innoapparent distress*, looksgivenage*, well developed*, goodattentiontohygiene*, alert, breathingcomfortably, cachectic, chronicallyill,comfortable,cooperative,distressed,frail,innoapparentdistress, malnourished,moderatelyoverweight,moderatelyuncomfortable,morbidlyobese,non-toxic,oriented, overweight,petite,pleasant,pregnant,sleepy,somewhattired,thin,uncomfortable,undernourished, witha pleasantexpression withanasarca]. Orientedto[person*, place*, time*, personbutnotplace ortime, place butnot personortime, time but notpersonor place]. Mood and affectappear[normal andappropriate tosituation*, agitated,angered,anxious,appropriate for age,appropriate tothe situation,argumentative,calm, confrontational,cooperative,depressed, fidgety,flat,frustrated,fussy,happy,labile,manic,manipulative,normal,overlyhappy,pleasant,quiet, sad,stressed,tearful,tense,tired, uncomfortable].
  15. 15. 14 Cardiovascular: Skintemperature is[OPTION=warmtocool proximal todistal*,cool tocool proximal todistal, warmto warm proximal todistal] onthe rightfootand [warmto cool proximal todistal*, cool to cool proximal to distal, warmto warmproximal todistal] onthe leftfoot. Dorsalispedispulsesare [OPTION=0/4, 1/4, 2/4, 3/4, 4/4, non-palpable, palpable, diminished, absent, bounding] leftand[0/4,1/4, 2/4, 3/4, 4/4, non-palpable, palpable, diminished, absent, bounding] right. Posteriortibial pulsesare [OPTION=0/4,1/4, 2/4, 3/4, 4/4, non-palpable, palpable, diminished, absent, bounding] leftand[0/4,1/4, 2/4, 3/4, 4/4, non-palpable, palpable, diminished, absent, bounding] right. Capillaryfill timeis[OPTION=<3seconds, 3-5 seconds, >5 seconds, delayed, immediate*] leftand [OPTION=<3 seconds, 3-5seconds, >5 seconds, delayed, immediate*] right. [No*, pitting, +1, +2, +3, +4] edemaispresent[OPTION=rightlowerextremity, leftlowerextremities, bilateral lowerextremities*]. Varicosities[OPTION=are, are not*] notedto[OPTION=rightlowerextremity, leftlowerextremities, bilateral lowerextremities*]. Skin: Skincoloris notedtobe [normal*, withinnormal limits, cyanotic, reddened, dark]. Skintexture isnotedtobe [normal*, healthyappearing, WNL, thin, dry, atrophic] Examinationof [hotspots]reveals[painful, erythematous, hyperkeratotic] areawithevidence of [adark object, glass] presentwithinthe [superficialskin, dermis, epidermis]. The area[doesnotappearto be infected, appearstobe infectedwithassociatedpurulentdrainage, appearstobe infected with associatedcellulitis]. Neurological: Vibratorysensationis[absent, diminished, present*] forleftfootand[absent, diminished, present*] for rightfoot. Sharp-dull sensationis[absent, diminished, present*, excessive] forleftfootand[absent,diminished, present*, excessive] forrightfoot. Lighttouch sensationis[absent, diminished, present*] forleftfootand[absent, diminished, present*] for rightfoot. Deeptendonreflexesare [OPTION=absent, diminished, normal*]. Coordinationis[OPTION=good*, fair, poor] Musculoskeletal: Muscle strengthof extremitiesis[normal*,diminishedleft,diminished right].
  16. 16. 15 Manual muscle testingis[OPTION=1, 2, 3, 4, 5] outof 5 forall groups. Impression: Plan: PatientwasinstructedonlukewarmwatersoakswithEpsomsaltsbidx 3 days and applydressing changesdaily. X-raystakenand reviewed I&D of foreignbody Figure 3 - Screw Foot and Flip-Flop Sandal Hyperkeratosis- Initial Patient:[Patient.Name]AccountNo:[Patient.AcctNo] Date:[Date] Chief Complaint:This[Patient.Age]yearold[Patient.Gender] presentstodaywithacomplaintof a [new onset, chronic, tender, painful] callousformationbeneaththe [first, second, third, fourth, fifth] [right,
  17. 17. 16 left] metatarsal headwithpainupon[standing, walking, exercise, performingworkduties, barefoot walking, closed-toeshoe gear, andevenwhenoff weight-bearing].The conditionhasbeenpresentfor [days, weeks, months, years] andrecentlyis[worsened, the same, improved].She hasattempted[self- debridement,soaks, lotions, OTCpadding, shoe gearchanges] which[have, have not] provided relief. Patient[has, hasnot] hada similarconditionpreviously.She [admits, denies] anyrecenttrauma or incitingevents. She [has, hasnot] notedanydrainage orbleedingfromthe area.She [admits, denies] a historyor poor circulationorlossof protective sensationinthe feet. Allergies: [Allergies] Medications:[Meds] Past Medical History:[PMH] Past Surgical History:[PSH] Past FamilyandSocial History:[PFH] [Social History] Reviewof Systems: Constitutional:[Constitutional] ENMT: [ENMT] Cardiovascular:[CV] Respiratory:[Respiratory] GI: [GI] GU: [GU] Immunologic:[Immunologic] Endocrine: [Endocrine] Hematologic/Lymphatic:[Hematologic/Lymphatic] Integumentary: [Integumentary] Musculoskeletal: [MSK] Neurological: [Neurological] Psychiatric: [Psychiatric] Examination: The patientisappropriatelydressed,articulate,awake,alert,andorientedx 3,appears theirstatedage and appearsto be in goodhealth.Theirvitalsare asfollows:[Vitals].
  18. 18. 17 Vascular:Dorsalispedispulsesare [0, 1, 2, 3, 4]/4 leftand[0, 1, 2, 3, 4]/4 right.Posteriortibial pulsesare [0, 1, 2, 3, 4]/4 leftand[0, 1, 2, 3, 4]/4 right.Capillaryrefilltime withthe legelevatedis[<3, 3, >3] secondsat the level of the digital tuftsbilaterally.There are noischemicskinchangesevidentineither lowerextremity.Edema[is, isnot] notedinthe [right, left, either, both] [foot, feet, ankle, leg]. Musculoskeletal:There ispainonpalpationof the plantaraspectof the [first, second, third, fourth, fifth] [right, left] metatarsal where ahyperkeratoticlesionis evident. The associatedtoe [is, isnot] contractedat the [MTPJ, PIPJ, DIPJ].The contracture is[mild, moderate, severe] andis[rigid, semi-rigid, reducible] atthe [PIPJ, DIPJ] with[mild, moderate, severe]dorsiflexioncontracture evidentatthe MTPJ whichis[reducible,semi-rigid,rigid]. EHL tendoncontracture [is, isnot] significant.The associateddigit isstable to modifiedLachmantestandthere [is, isno] painon palpationof the plantarplate. There are no othersignificantfootorankle deformitiesappreciatedbilaterally. Neurological:DeeptendonreflexesincludingAchillesandPatellarare normal,brisk,andsymmetrical bilaterally.Epicriticsensationincludingsharp-dull,lighttouch,proprioception,2-pointdiscrimination(< 12 mm at level of hallux tuft),vibration(128MHz tuningfork) andprotective threshold(10.0 gram monofilament) are intact. Nofocal motoror sensorydeficitsnotedineitherlowerextremity.There are down-goingtoesandanegative clonusbilaterally.Normalmuscle massisappreciatedinbothlower extremitiesincludingthe feet.Negative Mulder`ssigntothe interspacesof bothfeet. Painperceptionis normal on palpationof the hyperkeratoticlesionandassociatedtoe. Dermatological:There isadeepseatedhyperkeratoticlesionunderlyingthe [right, left][1st ,2nd , 3rd ,4th ,5th ] metatarsal headwhich,afterdebridement,[does, doesnot] reveal anyverruca-typetissue, characteristics of malignancy,evidence of foreignbodiesorgranulomas,orcardinal signsof infection. Comprehensivereviewandinspectionof the integumentof bothlower extremities [reveals, revealsno] evidence of edema,erythema,ecchymosis,openlesions,interdigital macerationorsignsof bacterial or fungal infection.Novaricosities,telangectasias,pigmentedlesionsorsignsof venousstasischanges notedineitherlowerextremity. [Adequate, Inadequate] fatpaddingtothe inferioraspectof eachfoot appreciated. Impression:Symptomaticlessermetatarsaldeformity[leftfoot, rightfoot, bothfeet] producinga chronicpainful benignhyperkeratoticlesionanddifficultyambulating.Noevidence of ulceration, infection,foreignbody,orsuspiciousskinchangeswerenoted. Treatment:Ihave discussedthe treatmentoptionswiththe patientandhave [debridedthe lesionfull thickness, dispensedsome silicone paddingwhichpatientwillreapplyona dailybasis, recommended use of Vaseline orsimilarproducttodecrease friction, stretchedshoes, instructedpatienttopurchase widerandextra-depthshoeswithalowheel andstiff sole aswell].[Idispensedsoftaccommodative insolestocushionandcradle the deformity].Discussedandrecommendedmore permanentcustom orthoticdevicesshouldthe accommodative measuresappliedtodayprovideadequaterelief of symptoms.If these conservative measuresfailtorelieve symptoms,Ibrieflyadvisedthe patientof the surgical optionsavailabletocorrectthe underlyingmetatarsal deformity.Iwill discussthose optionsin greaterdetail withthe patientinthe future if non-surgical treatmentsfail toprovidelong-term satisfactoryreliefof symptoms. RTC on a PRN basisforfollowupcare if the painpersistsorworsens.RTCASAPif problemssuchas increasingpain,redness,swelling,ordrainage are noted,orotherproblemsarise.
  19. 19. 18 Hyperkeratosis - Follow-up Patient:[Patient.Name]AccountNo:[Patient.AcctNo] Date:[Date] Subjective:Patientpresentstodayforfollow-upof arecurrentandchronic callousformationunderlying a lessermetatarsal deformitywithpainassociatedwithclosed-toedshoe gear. Patientdidwell withthe debridementandpaddingbuthave noticedasignificantrecurrence of the callousformationand discomfortevenwiththe changesinshoe gearandpadding. PMH, PSH, Medications:Unchangedsince lastvisit. Objective:The patient'sneurovascularstatusof bilateral lowerextremityisunchangedsince lastvisit. Musculoskeletal:There ispainonpalpationof the plantar[first, second, third, fourth, fifth] [right, left] metatarsal headwhere ahyperkeratoticlesionisevident. The metatarsal continuestobe elongatedand plantardisplacedcompared tothe adjacentmetatarsals.There are noothersignificantfootorankle deformitiesappreciatedbilaterally. Dermatological:There isadeepseatedhyperkeratoticlesionplantartothe [first, second, third, fourth, fifth] [right, left]metatarsal headof the [right, left, bilateral] footwhichafterdebridementdoesnot reveal anyverruca-type tissue,retainedforeignbodies,orcardinal signsof infection. Otherwise,there is no evidence of edema,erythema,ecchymosis,openlesions,interdigital macerationorsignsof bacterial or fungal infectionof bilateral lowerextremities. Novaricosities,telangectasias,pigmentedlesionsor signsof venousstasischangesbilateral lowerextremities. Adequatefatpaddingtothe inferioraspectof each footappreciated. Assessment: Symptomaticlessermetatarsal deformity[right, left, bilateral] foot. Plan:I have discussedthe previousthe treatmentoptionswiththe patientandhave debridedthe lesion full thickness.Recommendedcontinueduse of the paddingandinsolesdispensedatpreviousvisit, recommendeduse of Vaseline orsimilarproducttodecrease friction,andhave againstretchedtheir shoes.Since patienthasnotrealizedsignificantlong-termbenefitfromtheseconservativemeasuresI recommendedametatarsal osteotomytocorrectthe condition. Theyhave beenadvisedof the approximate disabilityinvolvedforthese procedures. Inaddition,the patienthasbeenadvisedastothe alternativesof care,includingcontinuedconservative care aswell assurgical procedures. The patient understandsthatif surgical proceduresare performed,there are risksandcomplicationsthatcould occur, includingbutnotlimitedto:hematomaformation,seromaformation,developmentof aDVT or phlebitis,infection,painful scartissue formation,limitedmotion,delayedunion,nonunion,malunion, reactionto implantedbiomaterials,over-correction,undercorrectionwithrecurrence of the deformities,continuedpain,andthe possibilitythatfuture surgerymayneedtobe performed. The patientwasgiventhe opportunitytoaskquestionswhichwere answeredtothe bestof myability. The patientvoicednoconcernsandwill considerall these optionsandschedule accordingly.
  20. 20. 19 Hyperkeratosis Debridement Hyperkeratotic[lesionwas*,lesionswere]debridedthisdate.Patientnotedreducedpainandimproved ambulationfollowingthe procedure. Incision & Drainage – Established Patient Patient:[Patient.Name]AccountNo:[Patient.AcctNo] Date:[Date] Chief Complaint:This[Patient.Age]yearold[Patient.Gender] presentstodaywithacomplaintof an ingrown[right,left] [hallux, 1sttoe, 2ndtoe, 3rd toe, 4th toe, 5th toe, foot, ankle, leg].Statesthe problemis[acute, chronic].The patientadmitsto[odor, redness, swelling, drainage, painassociated withclosed-toe shoegear, nail comingloose].Previoustreatments:[self-debridement, soaks, local woundcare,surgical procedures,evaluationbyanotherphysicianandreferral toPodiatry]. Patient statesthisproblem aReviewof Systems e from[anunknowncause, pedicure, trauma, impropercutting of nails]. Allergies: [Allergies] Medications:[Meds] Reviewof Systems: Constitutionalsymptoms:[Constitutional] Musculoskeletal: [MSK] Integumentary: [Integumentary] Endocrine: [Endocrine] Vitals:[Vitals] Examination:The patientisappropriatelydressed,articulate,awake,alert,andorientedx 3,appears statedage and looksto be in goodhealth. Dermatological:The [right, left] [1stdigit, 2nddigit, 3rddigit, 4th digit, 5thdigit, foot, ankle, leg] [medial border, lateral border, entire nail plate] is[erythematous, edematous, hot, withpurulentdrainage, with serosanginousdrainage, withnodrainage, incurvatedatthe nail fold, hypertrophiedatthe nail labia]. Otherwise,noopenlesionsorsignsof bacterial orfungal infectiontothe remainderof either foot. Vascular:Dorsalispedisandposteriortibialpulsesare [0, 1, 2, 3, 4]/4 bilateral.Capillaryfillingtime with the legelevatedis[<5, 5,>5] secondsat the level of the digital tuftsbilaterally.There [are, are not] ischemicskinchangesevident.
  21. 21. 20 Impression:[abscess,ingrowntoenail, sub-ungalulcer, cellulitis] Treatment:Ihave discussedthe treatmentoptionswiththe patientanddue tothe infectednature of the area I recommendedanincisionanddrainage withremoval of all infectedtissue.Idiscussedthe risks,complications,andexpectedrecoverycourse withthe patientandtheyunderstandthe nail margin will regrowandmaybecome symptomaticagaininthe future. Afterobtainingappropriateinformed consentandverifyingthe correctdigit,the toe was[anesthetizedwith3ccof a half and half solutionof 0.5% Marcaine™ plainand 1% lidocaine plainafter whichthe digitwas] preppedanddrapedinthe usual asepticmanner.Verificationof anesthesiawasperformed.[A tourniquetwasappliedtothe toe for10 minutes].The [areawasincisedanddrained, offendingnail borderwasremovedandirrigatedwith hydrogenperoxide].Pus[was, wasnot] expressed.Bacitracinanda dry sterile dressingwasapplied. [The tourniquetwasremoved].Explicitoral andwrittenpostoperative instructionswere dispensed.We will see the patientinfollow-upin[11days, 1 week, 2weeks, prn]. Incision & Drainage –New Patient Patient:[Patient.Name]AccountNo:[Patient.AcctNo] Date:[Date] Chief Complaint:This[Patient.Age]yearold[Patient.Gender] presentstodaywithacomplaintof [an ingrownnail, aninfectedtoenail, apainful nail, anabscess,aredarea] of the [right, left, bilateral] [hallux, 2ndtoe, 3rd toe, 4th toe, 5th toe, foot, leg].Statesthe problemis[acute, chronic, beenpresent for a while butthoughtitwouldresolve onitsown].The patientadmitsto[odor, redness, clear drainage, pusdraining, painassociatedwithclosed-toeshoe gear, burning, heat, pain].Previous treatments:[antibioticsprescribedbyanotherphysician, self-debridement, soaks, local woundcare, surgical procedures, nothingasitistoo painful totouch, benignneglect].Patientstatesthisproblem arose from [anunknowncause, pedicure, trauma, impropercuttingof nails, improperlyfittedshoes, trauma, swellingof the legsandfeet]. Allergies: [Allergies] Medications:[Meds] Past Medical History:[PMH] Past Surgical History:[PSH] Past FamilyandSocial History:[PFH];[Social History] Reviewof Systems: Constitutional:[Constitutional] ENMT: [ENMT]
  22. 22. 21 Cardiovascular:[CV] Respiratory:[Respiratory] GI: [GI] GU: [GU] Immunologic:[Immunologic] Endocrine: [Endocrine] Hematologic/Lymphatic:[Hematologic/Lymphatic] Integumentary: [Integumentary] Musculoskeletal: [MSK] Neurological: [Neurological] Psychiatric: [Psychiatric] Examination:The patientisappropriatelydressed,articulate,awake,alert,andorientedx 3,appears theirstatedage and appearsto be in goodhealth.Theirvitalsare asfollows:[Vitals]. Dermatological:The [right, left] [1stdigit,2nddigit, 3rddigit, 4th digit, 5thdigit, foot, ankle, leg] [medial border, lateral border, entire nail plate] is[erythematous, edematous, withpurulentdrainage, with serosanginousdrainage, withnodrainage, incurvatedatthe nail fold, hypertrophiedatthe labial nail, withgranulomatous lesion, loose fromthe nail bedpartially, loose fromthe nail bedcompletely].[No openlesionsorsignsof bacterial orfungal infectiontothe remainderof eitherfoot]. Neurological:Protective sensation[intact, diminished, absent].Pain[is, isnot] appreciatedtothe area. Vascular:Dorsalispedisandposteriortibialpulsesare [0, 1, 2, 3, 4]/4 bilateral.Capillaryfillingtime with the legelevatedis[<5, 5, >5] secondsatthe level of the digital tuftsbilaterally.There [are, are not] ischemicskinchangesevident. Musculoskeletal: [Muscle strengthforall prime moversof the footare intact bilateral withappropriate muscle tone andsymmetryandfull range of motionforall jointswithoutcrepitationorinstability appreciated, muscle weaknessappreciatedasaresultformedical status, limitationof motionand stiffnessappreciatedasa resultof currentmedical condition]. Impression:[paronychia, severe abscess, symptomaticingrowntoenail, sub-ungalulcer, granuloma, hematoma, seroma,ulceration, subungual ulcer, cellulitis] [1R, 2R, 3R, 4R, 5R, 1L, 2L, 3L, 4L, 5L, right foot, rightleg, leftfoot, leftleg][medial border, lateral border, entire nailplate] Plan:I have discussedthe treatmentoptionswiththe patientanddue to the nature of the infection,I recommendeda[slantbackprocedure, incisionanddrainage withremovalof all infectedtissueandthe nail margin, permanentremoval of the nail margintopreventfuture complications, removal of loose nail plate, chemical cauterizationof the granuloma, incisionanddrainage of wound, monitoringthe for
  23. 23. 22 improvement].Idiscussedthe risks,complications,andexpectedrecoverycourse withthe patientand theyunderstandthe areamay become symptomaticagaininthe future. Treatment:Appropriate informedconsentwasobtainedandverificationof the correctdigitwasdone. [The toe was anesthetizedwith3ccof a half andhalf solutionof 0.5% Marcaine™ plainand1% lidocaine plain, Noanesthesiawasrequiredasthe patientwas insensateenoughtotolerate the procedure, the digitwaspreppedinthe usual asepticmanner].A tourniquetwas[appliedtothe digit,applied tothe ankle,notapplied].[The offendingnail borderwasremovedalongwithall granulomatousand devitalized tissue andthenthe woundwasirrigatedwithhydrogenperoxide anddressedwithbacitracin and a dry sterile dressing, 3applicationsof phenol(89% CarbolicAcid) at30 secondseachwere applied viamicro tipcotton applicatorthenthe areawas irrigated withisopropyl alcohol.The digitwassprayed withhydrogenperoxide solutionwhichdiscolorsthe phenolinaneffortidentifyandremove inadvertent contact of the phenol withnormal skin.Amerigel®wasappliedtothe woundtoneutralize the phenol, the nail plate wasfreedfromthe nail bedand the woundwasdressedwithbacitracinanda non- adherentdressing,the granulomatouslesionwasdebridedwithsilvernitrate,the granulomatouslesion was debridedbywayof sharpexcision,the areawasincisedand drainedof all pusandfluid accumulationscreatingahealthywoundbase andirrigatedwithNSS].A lightlycompressivedressing was appliedwithaprotective outerdressing. [The tourniquetwasremoved].Explicitoral andwritten postoperative instructionswere dispensed.We willsee the patientinfollow-upin[1week, 11 days, 2 weeks,prn]. Shouldproblemsarise patientagreestocome to the office forevaluation. Ingrown Nail – Follow-up Patient:[Patient.Name]AccountNo:[Patient.AcctNo] Date:[Date] Subjective:Patientreturns2weekssince undergoinganail marginprocedure on[right, left, bilateral] [1st, 2nd,3rd, 4th, 5th] digit. Patienthasbeendoingverywell sincelastvisitandhasbeenvery compliantwithpostoperativeinstructions,soakingBiDwithQ-tipcleansingof the offendingnail margin, use of topical antibiotics,bandage coverage,anduse of open-toe shoe gearasmuchas possible.The patientdeniesanyfever,chills,nauseaorvomiting,calf painortenderness,shortnessof breath,chest pain,and local or systemicsignsof infection. Objective: Nochange fromthe previousmusculoskeletalexaminationof bilateral lowerextremity.The offendingnail marginis[cleananddryand intactwithno evidence of earlyrecurrence, draining serosanginousfluid,drainingpurulentfluid,erythematous].Thereisnopainon palpationof the offendingnail margin. Assessment:statuspostnail procedure [1,2, 3, 4, 5] [right,left] [doingwell, unchanged, worsening]. Plan:I cleansedthe toenail marginforthe patientandrecommended[dischargefromcare as woundis healed, continueduse of topical antibioticsandbandage application,use of anopen-toe shoe whenever possible,dailysoaksuntil astable escharhasformed].Iwill see patientbackona [PRN basis, in1 week, in2 weeks] andhave cautionedpatientregardingnail regrowthand/orrecurrence.
  24. 24. 23 Figure 4 - Healing Progression of Postoperative Ingrown Toenail Kissing corn Patient:[Patient.Name]AccountNo:[Patient.AcctNo] Date:[Date] Subjective:Patientpresentstodayforfollow-upof arecurrentandchronic callousformationbetween the toesin the [1st,2nd, 3rd, 4th] innerspace of the [right,left] foot.Thisisassociatedwithpainin closed-toedshoegear. Patientdidwell withthe debridementandpaddingbuthave noticeda significantrecurrence of the callousformationanddiscomfortevenwiththe changesinshoe gearand padding. PMH, PSH, Medications:Unchangedsince lastvisit. Objective:The patient'sneurovascularstatusof bilateral lowerextremityisunchangedsincelastvisit. Musculoskeletal:There [is, isnot] painonpalpationof the [1st,2nd, 3rd, 4th] webspace of the [right, left] footwhere ahyperkeratoticlesionisevident. There are noothersignificantfootorankle deformitiesappreciatedbilaterally.
  25. 25. 24 Dermatological:There isadeepseatedhyperkeratoticlesioninthe webspacewhichafterdebridement doesnotreveal anyverruca-type tissue,retainedforeignbodies,orcardinal signsof infection. Otherwise,thereisnoevidence of edema,erythema,ecchymosis,openlesions,interdigital maceration or signsof bacterial or fungal infectionof bilateral lowerextremities. Novaricosities,telangectasias, pigmentedlesionsorsignsof venousstasischangesbilateral lowerextremities. Adequatefatpaddingto the inferioraspectof eachfootappreciated. Radiographs:Reveal [nogrossbonyabnormalities,hypertrophiccondyle adjacenttothe lesion, underlappingdigitadjacenttothe lesion]. Assessment:Symptomatichelomamolle [1st ,2nd ,3rd , 4th ] innerspace of the [right,left] foot. Plan:I have discussedthe treatmentoptionswiththe patientandhave debridedthe lesionfull thickness.Recommendedcontinueduse of the paddingandinsolesdispensedatpreviousvisit, recommendeduse of Vaseline orsimilarproducttodecrease friction,andhave againstretchedtheir shoes.Since patienthasnotrealizedsignificantlong-termbenefitfromtheseconservativemeasuresI recommendedaprocedure tocorrectthe condition. The recommendedprocedure is[percutaneous osteotripsy, arthroplasty, exostectomy, ostectomy,partial saucerization] of the involvedphalangesof the [right,left] [1st,2nd,3rd, 4th, 5th] digits.Theyhave beenadvisedof the approximate disability involvedforthese procedures. Inaddition,the patienthasbeenadvisedas tothe alternativesof care, includingcontinuedconservative care aswell assurgical procedures. The patientunderstandsthatif surgical proceduresare performed,thereare risksandcomplicationsthatcouldoccur,includingbutnot limitedto:hematomaformation,seromaformation,developmentof a DVTor phlebitis,infection, painful scartissue formation,limitedmotion,delayedunion,nonunion,malunion,reactiontoimplanted biomaterials,over-correction,undercorrectionwithrecurrence of the deformities,continuedpain,and the possibilitythatfuture surgerymayneedto be performed. The patientwasgiventhe opportunityto ask questionswhichwereansweredtothe bestof myability. The patientvoicednoconcernsandwill considerall these optionsandschedule accordingly. Figure 5 - Soft Kissing Corn
  26. 26. 25 Lesion Description Lesionissurface isdescribedas[pigmentedblack, pigmentedbrown, pigmentedblue, homogenousin color, heterogeneous incolor].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] longby[1 , 2, 3, 4, 5, 6, 7, 8, 9, 10] [mm, cm, inches] wide.The bordersare describedas[regular, irregular, notwell defined, welldefined, serpintiginous, rolled, hyperkeratotic].[hotspots]. Nail Avulsion - Initial Patient:[Patient.Name]AccountNo:[Patient.AcctNo] Date:[Date] Provider:[Provider.Name] Chief Complaint: Patientisa[Patient.Age]yearold[Patient.Gender] whopresentstodaywithcomplaint of painful [ingrown, thickened, loosened] nail,on[right, left, bilateral] [1, 2, 3, 4, 5] toe whichhas had some slightodor,slightredness,cleardrainage,andpainassociatedwithclosed-toeshoe gearandhas not respondedtoself-debridement,soaks,andlocal woundcare.The problemhasbeenpresentfor [days, weeks, months].Patientisinterestedintreatmentoptions. Allergies: [Allergies] Medications:[Meds] Past Medical History:[PMH] Past Surgical History:[PSH] FamilyHistory:[FamilyHistory] Social History:[Social History] Reviewof Systems: Constitutionalsymptoms:[Constitutional] Eyes:[Eyes] Ears, Nose,Mouth,Throat: [ENMT] Cardiovascular:[CV] Respiratory: [Respiratory] GI: [GI] GU: [GU]
  27. 27. 26 Musculoskeletal: [MSK] Integumentary: [Integumentary] Neurological: [Neurological] Psychiatric: [Psychiatric] Endocrine: [Endocrine] Hematologic/Lymphatic: [Lymphatic] Allergic/Immunologic:[Immunologic] Physical Examination: The patientisappropriatelydressed,articulate,awake,alert,andorientedx 3, appearsstatedage and looksto be ingood health. [Vitals] Dermatological:There iserythemaandedemabutno purulentdrainage,andanassociated[incurvated, thickened, loosened] nail withhypertrophiedlabialnail foldappreciatedtothe offending[right, left, bilateral] [medialborder, lateralborder, medial andlateral borders, entire] [1st ,2nd ,3rd , 4th , 5th ] nail. No proximal cellulitisordeepabscessevidentatthistime.Otherwise,noopenlesionsorsignsof bacterial or fungal infectiontothe remainderof eitherfoot. Neurological:Painisappreciatedtothe offending[right, left, bilateral] [medial,lateral, bothmedialand lateral] nail borderof the greattoe.DeeptendonreflexesincludingAchillesandPatellarare normal, brisk,andsymmetrical bilateral.Epicriticsensationincludingsharp-dull,lighttouch,proprioception,2- pointdiscrimination(<12 mm at level of hallux tuft),vibration(128 MHz tuningfork) andprotective threshold(10.0gram monofilament) are intactandwithoutfocal motoror sensorydeficitbilateral lower extremities.There are downgoingtoesanda negative clonusbilateral.Normalmuscle massappreciated to boththe lowerextremityandfootbilateral.The patientcanheel andtoe walkwithease aswell as arise froma seatedpositionunassisted. Vascular:Dorsalispedisandposteriortibialpulsesare [0, 1, 2*, 3, 4]/4 bilateral.Capillaryfillingtime withthe legis[<3*, 3, >3] secondsat the level of the digital tuftsbilateral.There are noischemicskin changesevidentinbilateral lowerextremities. Musculoskeletal:Properalignmenttothe lowerlegs,stableankle tomanual stress(inversionand anteriordrawer),hindfoot,mid footandforefootbilateral lowerextremities.Muscle strengthforall prime moversof the lowerleg,ankle,andfootare gradedat 5/5 bilaterally.Appropriatemuscle tone and symmetryof bilateral lowerextremities.Full,fluidrange of motionforall jointsfromthe ankle joint distal withoutcrepitationorinstabilityappreciatedinbilateral lowerextremities. Impression: [Onychocryptisis, Onychomycosis, Onycholysis] [with, without] paronychia,[1st ,2nd ,3rd , 4th , 5th ] toe [right,left, bilateral] [medialborder, lateral border, bilateral borders, entire nail]. Treatment:Treatmentoptionswere discussed. Atthistime Irecommendednail avulsiontothe affected digits. Afterappropriate consentandverifyingthe correct[digit, digits],the toe wasanesthetizedwith3
  28. 28. 27 cc of 1:1 mixture of 0.5% Marcaine plainand1% lidocaine plain. A tourniquetwasappliedtothe toe(s). The offendingnail border(s) wasavulsed. The tourniquetwasremovedafterverifyingthatall pathologic nail tissue wasremoved,andanantibiotic-impregnatedcompressiondressingappliedtothe toe itself. Explicitoral andwrittenpostoperative instructionswere dispensed. We will seethe patientinfollow up intwo weeks’time orsoonershouldproblemsarise. [Provider.Name] cc: [Referral.Name] Nail Avulsion - Follow-up Patient:[Patient.Name]AccountNo:[Patient.AcctNo] Date:[Date] Provider:[Provider.Name] Subjective:Patientreturns2weeks since undergoinganail avulsionon[right, left, bilateral][1st ,2nd , 3rd , 4th , 5th ] digit. Patienthasbeendoingverywell since lastvisitandhasbeenverycompliantwith postoperative instructions,includingsoaksanddressingchanges.The patient statesthe digitis[not improved, mildlyimproved, greatlyimproved*]. Ptrelates[no, mild*, moderate] drainage. The patient [has, has not] beentakingoral antibiotics. Objective:The patientis[intact, diminished] fromaneurovascularstandpoint.No change fromthe previousmusculoskeletal examinationof bilaterallowerextremity.The offendingnail marginishealing well with[wet*, dry] escarand[no, mild*,moderate] marginalerythemapresent.There is[no, mild*, moderate] painonpalpation of the offendingnail margin. [No, Mild*,Moderate] serousdrainage present. Assessment:2weeksstatuspostnail avulsion,[improving*,worsening, unchanged, resolved]. Plan:I cleansedthe toenail marginforthe patientandrecommendedcontinueduse of topical antibiotics,dailydressingchanges,andsoaksuntil the drainage hasstopped,anduntil astable eschar has formed,atwhichpointthe above home care may be discontinued.The patientwillfollow up[2 weeks, 4weeks, 10 weeks,PRN*].Ihave cautionedpatientregardingnail regrowthand/or recurrence. Shouldthe physical therapist notice anyincreasedpain,swelling,rednessordrainage they will contactthe office immediately. Onychomycosis - Established Patient Patient:[Patient.Name]AccountNo:[Patient.AcctNo] Date:[Date]
  29. 29. 28 Subjective:Patientisa[Patient.Age] yearold[Patient.Gender] whopresentstoday[ambulating, ina wheelchair, usingawalker, usingacane] forevaluationandtreatmentof [onychomycosis, painful mycoticnails, diabeticcondition, podiatriccondition].The patienthasbeen[usingtopical ClarusAFoil on the nails, usingNAFTIN creamonthe nail bed(s) afternail removal, unabletoperformself-nail care due to the severe nature of nail deformitieswhichcause limitationinambulationdue topainand pressure inshoe gear, havingnailsprofessionallydone due tothe diabeticriskfactorsassociatedwith attemptedcare].Patientwaslastseenby 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 [improvingproximallybutstilldiscoloreddistally,resolvedinsignsof infection, elongated, thick, hypertrophic, crumbly, discolored, deformed, ridged, malodorous, lysing withfriable subungualdebriswhichafterdebridementtounderlyingnail bedrevealsacharacteristic fungal/yeast/moldodorandconsistency].There [is, isno] surroundingcellulitis.There [is, isno] deep incurvation.There [is, isnot] evidenceof bacterial infection.[Review of the integumentrevealedno woundswithinfectionnorulcerations, the webspacesare macerated.] The neurovascularstatusis unchangedascomparedto previousexaminations.Noischemiaorcyanosisnoted. Assessment:Symptomaticonychomycosiswith[improvementusingtopical treatments, improvedusing oral treatment, markedlimitationof ambulation, pain, ahighlikelihoodof complicationsif nottreated professionallyonaregularbasis]. Plan:[Mechanical andelectrical debridementof the mycotictoenailswasperformedandthe toenails were reduced toas normal a thicknessandlengththatpatienttolerance wouldallow].Thiswasdone on [1-5, 6-10] nails.[Thisimprovedthe texture, Thisgreatlyreducedthe painwithpressureappliedtothe nail plates].[The patient'sabilitytoambulate wasalsoobservedtobe improvedfollowing debridement].[Antifungal andantisepticsolutionwasappliedtothe nails].Advisedto[use AFnail oil, use tea tree oil, use Lamisil, continue touse lasertreatments, continuetouse nail oil toprevent recurrence, Onmel] totreatthe fungal infection.The patient[does,doesnot] desiretotreatthe infection. Returnto clinic[asneeded, 10weeks, 12 weeks, 6months, one year].
  30. 30. 29 Figure 6 - Proximal subungual onychomycosis (arrow) Onychomycosis - New Patient Patient:[Patient.Name]AccountNo:[Patient.AcctNo] Date:[Date] Chief Complaint: This[Patient.Age] yearold[Patient.Gender] presentstodayforevaluationand treatmentof [painful, discolored, thick, loose, mycotic, elongated] nails.The patient[hasbeenable, has beenunable, becauseof diabetesmellituswasadvisedbyPCPnot, because of use of bloodthinnerswas advisedby pcpnot] to provide self-nail care.[Due tothe severe nature of deformitythe nailscause limitationinambulationdue topainandpressure inshoe gear.] [Patienthasattemptedself- debridementwithlimitedsuccessorhascausedharm to themselves.] PatientwaslastseenbytheirPCP, [Patient.PrimaryPhysician] on[Patient.DateLastSeen]. Allergies: [Allergies] Medications:[Meds] Past Medical History:[PMH] Past Surgical History:[PSH] Past FamilyandSocial History:[PFH];[Social History]
  31. 31. 30 Reviewof Systems: Constitutional:[Constitutional] ENMT: [ENMT] Cardiovascular:[CV] Respiratory:[Respiratory] GI: [GI] GU: [GU] Immunologic:[Immunologic] Endocrine: [Endocrine] Hematologic/Lymphatic:[Hematologic/Lymphatic] Integumentary: [Integumentary] Musculoskeletal: [MSK] Neurological: [Neurological] Psychiatric: [Psychiatric] Examination:The patientisappropriatelydressed,articulate,awake,alert,andorientedx 3,appears theirstatedage and appearsto be in goodhealth.Theirvitalsare asfollows:[Vitals].The patient appears[well,poorly] nourishedand[well,poorly groomed],NAD. Vascular:Dorsalispedisare gradedat[0/4 b/l, 1/4 b/l, 2/4 b/l, 3/4 b/l, 4/4 b/l, monophasicb/l, biphasic b/l, triphasicb/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, monophasicleft, bipasicleft, triphasicleft, monophasicright, biphasicright, triphasicright, ] and posteriortibial pulsesare gradedat[0/4 b/l, 1/4 b/l, 2/4 b/l, 3/4 b/l, 4/4 b/l, monophasicb/l, biphasic b/l, triphasicb/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, monophasicleft, biphasicleft, triphasicleft] Digital hairgrowth[present, sparse, absent] bilateral. CFT withthe legelevatedwas[lessthan3 seconds, 3 seconds, more than3 seconds] at the distal toes bilateral.There [is,isnot] evidence of ischemicskinchanges.Temperature fromthe tibiatothe toesis [warm,cool] at anteriortibiato[warm,cool] at the distal digitsbilateral. Neurological: [CoordinationWNLtorightand leftlowerextremity, Protectivesensationgrossly intact, Protective sensationdiminished.] Dermatological:[Hotspots] is[mildly,severely,elongated, thickened, yellow/discolored, crumbly, ridged, lysingwithfriable subungualdebris].There is [surroundingcellulitis, deepincurvationof nail(s), evidence of surroundingbacterial infection, evidence of surroundingfungal infection, evidence of chronicpickingat the nail and ungal labia, abscess of nail(s),nopathologicskinchanges].Classfindings
  32. 32. 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/pedalhairgrowth,[no, mild, moderate, severe] telangectasiasand[no, mild, moderate, severe] lowerlegedema.Atriskareasare [present, absent].Openulcerationsare [absent,present]. Musculoskeletal:Patientis[able towalk,able towalkwithawalker,able towalkwitha cane,ina wheelchair].[Stable footposture withoutobviousstructural deformitiesnotedbilateral,Forefootand digital malpositioninfootstructure, Midfootmalpositioninfootstructure, Rearfootstructural malposition, Anklefootstructure malposition].Muscle strengthof the lowerextremityshows[normal, weak,absent] primarymovers.[Stiff contractedjointspresent., Fluidrange of motionforall jointsfrom the ankle to the distal toeswithoutcrepitationnotedbilateral., Range of motionof jointsislimited.] Assessment:Symptomaticonychomycosis[tineapedis, tineainterdigitus, onychocryptosis, ingrown toenail] Plan:The offendingnail platesandmarginswere mechanicallyandelectricallydebrided[1-5,6-10] in as normal thicknessandlengthasthe patientwouldtolerate.Thisrenderedthe patientasymptomaticwith appliedpressure tothe nail plate.[Thiswasalsoevidencedbypainfree ambulation].Antifungal and antisepticsolutionwasappliedtothe nails.Recommendpatientconsideroptionsof treatmentto include:[Clarus™topical oil, Penlac® topical agent, OTCAFtherapy, prescriptionstrengthAFtherapy, lasertreatment, oral antifungal therapy] onthe toenailstoattempttotreatthe fungal infection.Atthis pointthe patientelectstouse [Clarus™ topical oil,Penlac® topical agent, OTCAFtherapy, prescription strengthAFtherapy, lasertreatment, oral antifungaltherapy]. Instructedtowashsocksinbleachas well as the bedsheets.AlsoinstructedtosprayshoeswithAF sprayeverynightandletdryovernight. Returnto clinic[asneeded, 10weeks, 12 weeks, 6months, 12 months]. Phenol and Alcohol Matrixectomy Treatment: I have discussedthe treatmentoptionswiththe patientanddue tothe painful nature of the toe and severe incurvatednail edge presentIrecommendpermanentremoval of the [entiretoenail, medial borderof toenail,lateral borderof toenail].Idiscussedthe risks,complications,andexpected recoverycourse withthe patientandtheyunderstandthe nail,nail margin,orspiculesof it,mayre-grow and maybecome symptomaticagaininthe future. Afterappropriate consentandverifyingthe correct digit,aninjectionwasperformedusing[1,2, 3*, 4, 5]cc of a 1:1 mix of 1% Lidocaine and0.5% Marcaine™ afterwhichit waspreppedanddrapedinthe usual asepticmanner.Verificationof anesthesiawasperformedafterwhichatourniquetwasappliedtothe toe.Uponproperanesthesia,the [entire toenail,medial borderof toenail,lateral borderof toenail, medial andlateral bordersof the toenail] wasfreedfromitssofttissue attachmentsandexcisedintoto.Areawasinspectedfor spicules and none were found. 3applicationsof phenol (89% CarbolicAcid) applied,for30 secondseachand the area irrigated withalcohol. The digitwassprayedwithhydrogenperoxide solutionwhichdiscolorsthe phenol inaneffortidentifyinadvertentburningof normal skin.Amerigel®wasappliedanda lightly compressive non-sticksteriledressing.The tourniquetwasremoved.A prompthyperemicresponse was notedto the toe.Explicitoral andwrittenpostoperative instructionswere dispenseddescribingthe post-operative care of the site.We will see the patientinfollow upintwoweeks’timeif neededor soonershouldproblemsarise.
  33. 33. 32 Phenol and Alcohol Matrixectomy – Established Patient Patient:[Patient.Name]AccountNo:[Patient.AcctNo] Date:[Date] Chief Complaint: Patientisa[Patient.Age]yearold[Patient.Gender] whopresentstodaywithcomplaint of chronicingrown nail on[right, left, bilateral][great, 2nd , 3rd , 4th , 5th] toe with[odor, erythema,clear drainage,cloudydrainage,painwithclosedtoedshoes] and[has,hasnot] respondedtoself- debridement,soaks,andlocal woundcare. Patienthashada similarconditionpreviouslytreated [conservatively, surgically, withdebridement] anddesirestohave a permanentprocedure sothe nail edge will notgrowback. Allergies: [Allergies] Medications:[Meds] Reviewof Systems: Constitutionalsymptoms:[Constitutional] Musculoskeletal: [MSK] Integumentary: [Integumentary] Neurological:[Neurological] Endocrine:[Endocrine] Physical Examination: The patientisappropriatelydressed,articulate,awake,alert,andorientedx 3, appearsstatedage and looksto be ingood health. Dermatological:There is[erythema, edema, pus, cleardrainage] andanassociatedincurvatednail with hypertrophiedlabial nailfoldappreciatedtothe offendingnail border. Vascular:Dorsalis pedisandposteriortibialpulsesare [0, 1, 2, 3, 4]/4 bilateral.Capillaryfillingtime with the legelevatedis[<5, 5, >5] secondsatthe level of the digital tuftsbilateral.There are noischemicskin changesevidentinbilateral lowerextremities. Impression: Chroniconychocryptosis [1, 2,3, 4, 5] [right, left, bilateral] [medial border, lateral border, medial andlateral borders,entirenail]. Treatment: I have discussedthe treatmentoptionswiththe patientanddue tothe chronic nature patientelectstohave the above nail(s) removedpermanently.Idiscussedthe risks,complications,and expectedrecoverycourse withthe patientandtheyunderstandthe nail margin,orspiculesof it,mayre- grow andmay become symptomaticagaininthe future. Afterappropriateconsentandverifyingthe correct digit(s),the toe wasanesthetizedwith3cc of 0.5% Marcaine™ plain,afterwhichitwasprepped
  34. 34. 33 and drapedinthe usual asepticmanner. Verificationof anesthesiawasperformedafterwhicha tourniquetwasappliedtothe toe. The offendingnail borderwasremoved,3applicationsof phenol (89% CarbolicAcid) applied,andthe areairrigatedwithalcohol. The digitwas sprayed withhydrogen peroxide solutionwhichdiscolorsthe phenolinanefforttoidentifyinadvertentburningof normal skin. Amerigel®waspackedinthe woundanda lightlycompressive drysterile dressingwasapplied.The tourniquetwasremoved. Explicitoral andwrittenpostoperative instructionswere dispensed. We will see the patientinfollowupintwoweek’stime orsoonershouldproblemsarise. Phenol and Alcohol Matrixectomy – New Patient Patient:[Patient.Name]AccountNo:[Patient.AcctNo] Date:[Date] Chief Complaint: Patientisa[Patient.Age]yearold[Patient.Gender] who presentstodaywithcomplaint of chronicingrownnail on[right, left, bilateral][great, 2nd , 3rd , 4th , 5th ] toe.Admits[pain, redness, drainage, odor, infection, paininshoe gear] andhasnot respondedtoself-debridement,soaks,andlocal woundcare. Previoustreatments:[notreatment,local woundcare, debridement, surgical procedures, soaks].[Patientdesirestohave apermanentprocedure sothe nail edge willnotgrow back]. Allergies: [Allergies] Medications:[Meds] Past Medical History:[PMH] Past Surgical History:[PSH] Past FamilyandSocial History:[PFH];[Social History] Reviewof Systems: Constitutional:[Constitutional] ENMT: [ENMT] Cardiovascular:[CV] Respiratory:[Respiratory] GI: [GI] GU: [GU] Immunologic:[Immunologic] Endocrine: [Endocrine]
  35. 35. 34 Hematologic/Lymphatic:[Hematologic/Lymphatic] Integumentary: [Integumentary] Musculoskeletal: [MSK] Neurological: [Neurological] Psychiatric: [Psychiatric] Examination:The patientis[appropriatelydressed, articulate, awake, alert, andorientedx 3] Patient appearsto be in [good, fair, poor, neglected] health. Vitalsare asfollows:[Vitals]. Dermatological:There is[erythemaandedema,purulentdrainage, incurvatednail withhypertrophied labial nail fold, nosignsatthistime as the nail isquiescent] appreciatedtothe offending[right, left, bilateral] [medial, lateral, medial andlateral] [hallux*, 2nd ,3rd , 4th , 5th ] nail border(s).[Proximal cellulitis, distal cellulitis,deepabscess] evident. Neurological:Pain[is*,isnot] appreciatedtothe offendingnail border(s). Epicriticsensationappears [intact, absent].The patient[canheel andtoe walkwithease, arise fromaseatedpositionunassisted, cannot walk]. Vascular:Dorsalispedisandposteriortibial pulsesare [0, 1, 2, 3, 4]/4 bilateral.Capillaryfillingtime with the legelevatedis[<3, 3, >3] secondsatthe level of the digital tuftsbilateral.There [are,are no] ischemicskinchangesevidentinbilateral lowerextremities. Impression: Chroniconychocryptosis[1, 2,3, 4, 5] [right, left, bilateral] [medial, lateral, medialand lateral] border(s). Treatment: I have discussedthe treatmentoptionswiththe patientanddue tothe chronic nature of the toenail andsevere incurvatednail edge presentIrecommendedaremoval of the nail margin(s) and all infectedtissue.Idiscussedthe risks,complications,andexpectedrecoverycourse withthe patient and theyunderstandthe nail margin,orspiculesof it,mayre-grow andmay become symptomaticagain inthe future. Afterappropriate consentandverifyingthe correctdigit,the toe wasanesthetizedwith3 cc of a 50/50 mixture of 0.5% Marcaine™ and 1% lidocaine plainafterwhichitwaspreppedanddraped inthe usual asepticmanner.Verification of anesthesiawasperformedafterwhichatourniquetwas appliedtothe toe. The offendingnail border(s)wasremoved,3applicationsof phenol (89% Carbolic Acid) applied,andthe areairrigatedwithalcohol.The digitwas sprayed withhydrogenperoxide solution whichdiscolorsthe phenol inaneffortidentifyinadvertentburningof normal skin.Amerigel®was appliedanda lightlycompressive drysteriledressing.The tourniquetwasremoved. Explicitoral and writtenpostoperative instructionswere dispensed.The patientwasgivenoptionstoeitheruse Amerigel®twice dailywithdressingchangesorsoakthe toe in Epsomsalts3 timesdailyfortenminutes each time afterwhichapplyadry sterile dressing.Patientwasadvisedtotake apainrelieverof their choice as needed.We will seethe patientinfollow upin11-14 day’stime or soonershouldproblems arise.
  36. 36. 35 Figure 7 – Phenol portion of Matrixectomy Partial Nail Avulsion – New Patient Patient:[Patient.Name]AccountNo: [Patient.AcctNo] Date:[Date] Chief Complaint:This[Patient.Age]yearold[Patient.Gender] presentstodaywithacomplaintof [an ingrownnail,aninfectedtoenail,apainful nail,anabscess,aredarea] of the [right, left, bilateral] [hallux, 2nd toe,3rd toe, 4th toe, 5th toe, foot, leg].Statesthe problemis[acute, chronic, beenpresentfor a while butthoughtitwouldresolve onitsown].The patientadmitsto[odor, redness, cleardrainage, pusdraining, painassociatedwithclosed-toeshoe gear, burning, heat,pain].Previoustreatments: [antibioticsprescribedbyanotherphysician, self-debridement, soaks, local woundcare, surgical procedures, nothingasitistoo painful totouch, benignneglect].Patientstatesthisproblemarose from [an unknowncause, pedicure, trauma, impropercuttingof nails, improperlyfittedshoes, trauma, swellingof the legsandfeet]. Allergies: [Allergies]
  37. 37. 36 Medications:[Meds] Past Medical History:[PMH] Past Surgical History:[PSH] Past FamilyandSocial History:[PFH];[Social History] Reviewof Systems: Constitutional:[Constitutional] ENMT: [ENMT] Cardiovascular:[CV] Respiratory:[Respiratory] GI: [GI] GU: [GU] Immunologic:[Immunologic] Endocrine: [Endocrine] Hematologic/Lymphatic: [Hematologic/Lymphatic] Integumentary: [Integumentary] Musculoskeletal: [MSK] Neurological: [Neurological] Psychiatric: [Psychiatric] Examination:The patientisappropriatelydressed,articulate,awake,alert,andorientedx 3,appears theirstatedage and appearsto be in goodhealth.Theirvitalsare asfollows:[Vitals]. 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, withpurulentdrainage, with serosanginousdrainage, withnodrainage, incurvatedatthe nail fold, hypertrophiedatthe labial nail, withgranulomatous lesion, loose fromthe nail bedpartially, loose fromthe nail bedcompletely].[No openlesionsorsignsof bacterial orfungal infectiontothe remainderof eitherfoot]. Neurological:Protective sensation[intact, diminished, absent].Pain[is, isnot] appreciatedtothe area. Vascular:Dorsalispedisandposteriortibialpulsesare [0, 1, 2, 3, 4]/4 bilateral.Capillaryfillingtime with the legelevatedis[<5, 5, >5] secondsatthe level of the digital tuftsbilaterally.There [are, are not] ischemicskinchangesevident.
  38. 38. 37 Musculoskeletal: [Muscle strengthforall prime moversof the footare intact bilateral withappropriate muscle tone andsymmetryandfull range of motionforall jointswithoutcrepitationorinstability appreciated, muscle weaknessappreciatedasaresultformedical status, limitationof motionand stiffnessappreciatedasa resultof currentmedical condition]. Impression:[paronychia, severe abscess, symptomaticingrowntoenail, sub-ungalulcer, granuloma, hematoma, seroma,ulceration, subungual ulcer, cellulitis] [1R, 2R, 3R, 4R, 5R, 1L, 2L, 3L, 4L, 5L, right foot, rightleg, leftfoot, leftleg][medial border, lateral border, entire nailplate] Plan: I have discussedthe treatmentoptionswiththe patientanddue tothe nature of the infection,I recommendedapartial nail avulsionof the offendingnail segment withremoval of all infectedtissue and hypertrophictissueinthe nail groove.Idiscussedthe risks,complications,andexpectedrecovery course withthe patientandtheyunderstandthe areamay become symptomaticagaininthe future. Treatment: Appropriate informedconsentwasobtainedandverificationof the correctdigitwasdone. [The toe was anesthetizedwith3cc,4cc,5cc,6cc of, a half and half solutionof 0.5% Marcaine™ plainand 1% lidocaine plain,2%lidocaine plain, Noanesthesiawasrequiredas the patientwasinsensate enough to tolerate the procedure, The digitwaspreppedinthe usual asepticmanner].[A digital tourniquetwas appliedandremovedatthe endof the procedure, notourniquetwasapplied].A partial avulsionof the offendingsegmentof nail wasperformedandall granulomatousanddevitalizedtissuewithinthe nail foldwasremoved.The woundwasthenirrigatedwithhydrogenperoxideanddressedwithbacitracin and a dry sterile lightlycompressive dressingwasapplied.[The patientwasgivenaprescriptionfor, The patientwasadvisedtodiscontinuethe medicationif side effectsarise andtonotifythe office immediatelyforadjustmentof the antibiotics, Antibioticswere notdeemednecessary.] [The tourniquetwasremoved]. Explicitoral andwrittenpostoperative instructionswere dispensedfordaily woundcare.We will see the patientinfollow-upin[1week, 11days, 2 weeks, prn] Shouldproblems arise earlierorsignsand symptomsof infectionworsenthe patientagreesto come tothe office for evaluation. Partially Avulsed Nail Patient:[Patient.Name]AccountNo:[Patient.AcctNo] Date:[Date] Chief Complaint:This[Patient.Age]yearold[Patient.Gender] presentstodaywithacomplaintof a [acute, chronic] avulsingnail of the [right,left] [1st ,2nd ,3rd , 4th , 5th ] digitwhichispainful andhas not respondedto[self-debridement, soaks, local woundcare]. Patient[has,hasnot] hada similarcondition previously.Patientstatesthisproblemarose from[pedicure,trauma,impropercuttingof nails]. Allergies: [Allergies] Medications:[Meds] Past Medical History:[PMH]
  39. 39. 38 Past Surgical History:[PSH] Past FamilyandSocial History:[PFSH] Reviewof Systems: Constitutionalsymptoms:[Constitutional] Eyes:[Eyes] Ears, Nose,Mouth,Throat: [ENMT] Cardiovascular:[CV] Respiratory: [Respiratory] GI: [GI] GU: [GU] Musculoskeletal: [MSK] Integumentary: [Integumentary] Neurological: [Neurological] Psychiatric: [Psychiatric] Endocrine: [Endocrine] Hematologic/Lymphatic: [Lymphatic] Allergic/Immunologic:[Immunologic] Examination:The patientisappropriatelydressed,articulate,awake,alert,andorientedx 3,appears statedage and looksto be in goodhealth. Dermatological:The nail of the [right,left][1st ,2nd ,3rd , 4th , 5th ] digitispartiallyavulsedwith[hematoma underthe nail plate,erythema,edema,drainage,odor]. Otherwise,noopenlesionsorsignsof bacterial or fungal infectiontothe remainderof eitherfoot. Neurological:Pain isappreciatedtothe offendingnail border.DeeptendonreflexesincludingAchilles and Patellarare normal,brisk,andsymmetrical bilateral.Epicriticsensationincludingsharp-dull,light touch,proprioception,2-pointdiscrimination(<12 mm at level of hallux tuft),vibration(128MHz tuning fork) and protective threshold(10.0gram monofilament) are intactandwithoutfocal motoror sensory deficitbilateral lowerextremities. Normal musclemassappreciatedtoboththe lowerextremityand footbilateral. Vascular:Dorsalispedisandposteriortibialpulsesof the effectedfootare [0, 1, 2, 3, 4]/4 bilateral. Capillaryfillingtime withthe legelevatedis[<5,5,>5] secondsat the level of the digital tuftsbilaterally. There are noischemicskinchangesevidenttobilateral lowerextremities.
  40. 40. 39 Musculoskeletal:Properalignmenttothe lowerlegs,stableankle tomanual stress(inversionand anteriordrawer),hindfoot,midfootandforefootbilateral lowerextremities.Muscle strengthforall prime moversof the lowerleg,ankle,andfootare gradedat 5/5 bilateral lowerextremities.Appropriate muscle tone andsymmetrybilateral lowerextremities.Full,fluidrange of motionforall jointsfromthe ankle jointdistal withoutcrepitationorinstabilityappreciatedbilateral lowerextremities. Impression:[traumaticnail avulsion,ingrowntoenail] Treatment:Ihave discussedthe treatmentoptionswiththe patientanddue tothe infectednature of the toe andsevere incurvatednail edgepresentIrecommendedanincisionanddrainage withremoval of all infectedtissue andthe nail margin.Idiscussedthe risks,complications,andexpectedrecovery course withthe patientandtheyunderstandthe nail marginwill regrow andmaybecome symptomatic againin the future. Afterobtainingappropriate informedconsentandverifyingthe correctdigit,the toe was anesthetizedwith3cc of a half andhalf solutionof 0.5% Marcaine™ plainand1% lidocaine plain afterwhichthe digitwaspreppedanddrapedinthe usual asepticmanner.Verificationof anesthesia was performedafterwhichatourniquetwasappliedtothe toe for5-10 minutes.The offendingnail borderwas removedandirrigatedwithhydrogenperoxide.Bacitracinandadry sterile dressingwas applied.The tourniquetwasremoved.Explicitoral andwrittenpostoperative instructionswere dispensed. Returnto clinicas neededandif problemsarise. Pigmented Lesion Patient:[Patient.Name]AccountNo:[Patient.AcctNo] Date:[Date] Chief Complaint:[Patient.FirstName] isa[Patient.Age] yearold[Patient.Gender] whopresentstoday witha complaintof a chronicpigmentedlesionwhichhasnotrespondedtosoaksandOTC paddingwith shoe gearchanges. They[have,have not*] had a similarconditionpreviouslyand denyanyrecent trauma or incitingevents. Theydonothave a familyhistoryof cutaneousmalignancyandhave nothad any similarlesionsonthe remainderof theirbodytreatedatany time. Allergies: [Allergies] Medications:[Meds] Past Medical History:[PMH] Past Surgical History:[PSH] Past FamilyandSocial History:[PFSH] Reviewof Systems:
  41. 41. 40 Constitutionalsymptoms:[Constitutional] Eyes:[Eyes] Ears, Nose,Mouth,Throat: [ENMT] Cardiovascular:[CV] Respiratory: [Respiratory] GI: [GI] GU: [GU] Musculoskeletal: [MSK] Integumentary: [Integumentary] Neurological: [Neurological] Psychiatric: [Psychiatric] Endocrine: [Endocrine] Hematologic/Lymphatic: [Lymphatic] Allergic/Immunologic:[Immunologic] Physical Examination:The patientisappropriatelydressed,articulate,awake,alert,andorientedx 3, appearstheirstatedage and appearsto be in goodhealth.Vascular:Dorsalispedisandposteriortibial pulsesare readilypalpable andgradedat2/4 bilateral.Capillaryfilling time withthe legelevatedis<5 secondsat the level of the digital tuftsbilateral.There are noischemicskinchangesevidentof bilateral lowerextremities.Musculoskeletal:Normal strength,range of motionandalignmentforall jointsfrom the ankle distal are evidentbilateral. Neurological:DeeptendonreflexesincludingAchillesandPatellar are normal,brisk,andsymmetrical bilateral.Epicriticsensationincludingsharp-dull,lighttouch, proprioception,2-pointdiscrimination(<12 mm at level of halluxtuft),vibration(128MHz tuningfork) and protective threshold(10.0gram monofilament)are intactandwithoutfocal motoror sensorydeficit bilateral lowerextremities.There are downgoingtoesanda negative clonusbilateral.Normal muscle mass appreciatedtoboththe lowerextremityandfootbilateral.Dermatological:There isaraised pigmentedlesiontotheirfoot/toe whichdoesnotshow anycardinal signsof cutaneousmalignancyor significantirritation. Otherwise,thereisnoevidenceof edema,erythema,ecchymosis,openlesions, interdigitalmacerationorsignsof bacterial orfungal infectionbilateral lowerextremities. No varicosities,telangiectasias,orsignsof venousstasischangesof bilateral lowerextremities. Adequate fat paddingtothe inferioraspectof eachfootis appreciated. Impression:Symptomaticpigmentedlesion
  42. 42. 41 Treatment:Ihave discussedthe treatmentoptionswiththe patientandhave recommendeduse of Vaselineorsimilarproducttodecrease frictionandeitherpurchasingwider,extra-depthshoe gearor stretchingtheircurrentshoes. Shouldthesemeasuresfail Irecommendedasimple excisionof the lesionunderlocal anesthesiaanddiscussedthe risks,complications,andexpectedrecoverycourse in detail.They will monitorthe lesionandlookforpatrioticsignsof change (i.e.,red,white,bluechanges) and if presentwill contactme immediately. We will see thembackona PRN basisor soonershould problemsarise. Figure 8 - Lesion noted by patient after a training run while wearing joggers PinPointe - Initial Patient:[Patient.Name]AccountNo:[Patient.AcctNo] Date:[Date] Chief Complaint: Discolorationof toenails.Conditionhasexistedfor[several months, overayear, many years].Condition[is, isnot] painful.Commencement was[insidious, sudden, unsure asnail polishhad beenonfor so long].Previoustreatmentsinclude:[evaluationbya previousphysician, overthe counter (OTC) topical agents, prescriptiontopical agents, oral Lamisilinpulse dose, oral Lamisil infull dose, laser treatments, overthe counter(OTC) remedies, notreatmentadministered].[Patienthasa historyof complicationswithoral medicines.]
  43. 43. 42 Allergies: [Allergies] Medications:[Meds] Past Medical History:[PMH] Past Surgical History:[PSH] Past FamilyandSocial History:[PFH] [Social History] Reviewof Systems: Eyes:[Eyes] GI: [GI] GU: [GU] Gynecological:[Gynecological] Musculoskeletal: [MSK] Integumentary: [Integumentary] Neurological: [Neurological] Psychiatric: [Psychiatric] Endocrine: [Endocrine] Physical Exam:[Vitals] Vascular: Dorsalispedisare gradedat[1,2,3,5,4] andposteriortibial pulsesare gradedat[1,2,3,5,4] with digital hairgrowth[present,absent] bilateral. CFTwiththe legelevatedwas[lessthan3 seconds,3 seconds,more than3 seconds] atthe distal toesbilateral. There [is,isnot] evidence of ischemicskin changes.Temperature fromthe tibiatothe toesis[warm, cool] at anteriortibiato [warm, cool] atthe distal digitsbilateral. Neurological: [CoordinationWNLtorightand leftlowerextremity] [Touchsensationsare withinnormal limits] Dermatological: There isnail [thickening, elongation, splitting, discoloration,incurvation] of [Hot Spots]. [There isnormal texture,temperature,turgorandcolorof the skin.] [There isevidence of peeling,scaling,andchronicdrynessof the skin] Musculoskeletal: Patientis[able towalkwithease,able towalkwithawalker, inawheelchair]. [Stable footposture withoutobviousstructural deformitiesnotedbilateral,malpositionof footstructure atthe
  44. 44. 43 level of the forefoot, malpositionof footstructure atthe level of the mid-foot, malpositionof foot structure at the level of the rear-foot, malpositionof footstructure atthe level of the ankle]. Impression: [Onycomycosis, hammertoes, tineapedis, onychogryphosis, ingrowntoenail] Plan: We discussedtreatmentof onychomycosis.We discussedtopical treatments,oral treatments,and lasertreatmentsusingthe PinPointelaser. Afterdiscussingthe options,the patientdecidedtotreat the onychomycosiswithPinPointe laser. The patientsignedthe consentformforthe treatment,andwas advisednottopainttoenails, duringtreatmentperiod,forthe nextseveral months.Patientwasadvised not to use nail salon,andnot topluck any material outfromunderthe nail edge.A photographwas takenof affectednails.[Manual andmechanical debridementof the mycoticnailswascarriedout.] The laserprocedure wasperformedon[all, bothhalluxnails,1R,2R,3R,4R,5R,1L,2L,3L,4L,5L] nailswithout complications.The patientwaslectured onthe importance of practicingpreventive measures, and writteninstructionswere given.Idispensedacomplimentaryantifungal spraytouse intheirshoes, and an antifungal creamtouse two timesaday for twoweeks,oruntil the skinisclearof infection.Theyare thento continue usingthe creamtwice weeklyasa lifestyle. Idiscussedcleansingthe showerswith householdbleachandwashingall socksandbedsheetsinbleach.All questionsanswered.The patient will RTCin [1 month,2months,3months,4months, PRN] forfollow-upinspectionandphotographs. Figure 9 – Pinpoint laser producer
  45. 45. 44 Figure 10 – After application of Pinpoint Figure 11 - PinPointe Laser machine PinPointe - Follow-up Patient: [Patient.Name] Account No: [Patient.AcctNo] Date: [Date] Chief Complaint:Thispatientreturnsforfollow upafterthe firstPinPointe lasertreatmentfor onychomycosis.The patient[is,isnot,intermittently] practicingthe preventivemeasurestoavert reinfectionbyusing[antifungal creamonthe skin,antifungal oilonthe nails,sprayingshoeswith Antifungal spray].The patient[has,hasnot] noticedasignificantimprovementinthe nail discoloration and texture.
  46. 46. 45 Physical Examination: There is[normal, abnormal] textureandcolorof the periungual skin. Plantar skinis[clearof infection, improvedinappearance of infection, notimprovedinappearance of infection]. Nailsare [improvingasexpected, improvingfasterthanexpected, improvingslowerthanexpected, not improving, worsening, resolvedinappearance of infection] Assessment: [onychomycosis, tinea pedis] [improving, unchanged, worsening, resolved] Plan: We discussedthe progress.Photographswere takentodocumentprogress.Patient waslectured, stressingthe importance of [continuingto practice preventivemeasuresusingthe same overthe counter(OTC) products, becomingmore aggressiveandmovingtoa prescriptionstrengthproduct]. [Retreatmentwiththe PinPointe laserappliedtothe toenailsinareasthatappearto be infectedwith fungus.] RTC [1 month, 2 months, 5 months, PRN] for follow-up inspection. Ulceration - Initial Visit Patient:[Patient.Name]AccountNo:[Patient.AcctNo] Date:[Date] Chief Complaint: This[Patient. Age] yearold[Patient. Gender] presentstodaywithan ulceration.The ulcerhas beenpresentforseveral [days,weeks,months,years].The conditionis[worsening, unchanged,improving].Patient[hasrespondedto,hasnotrespondedto,hasnotattempted] local woundcare.Last seenbyPCP,[Patient. Primary Physician] on[Patient. Date LastSeen]. Allergies: [Allergies] Medications:[Meds] Past Medical History:[PMH] Past Surgical History:[PSH] Past FamilyandSocial History:[PFH] [Social History] Reviewof Systems: Constitutional:[Constitutional] ENMT: [ENMT] Cardiovascular:[CV] Respiratory:[Respiratory] GI: [GI]

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