SOAP / Chart / Progress Notes
Sample Name: Foot Lesions
Description: Patient with complaint of a very painful left foot because of the lesions on the bottom of the foot.
(Medical Transcription Sample Report)
S - An 84-year-old diabetic female, 5'7-1/2" tall, 148 pounds, history of hypertension and diabetes. She presents today with complaint of a very painful left foot because of the lesions on the bottom of the foot. She also has a left great toenail that is giving her problems as well.
O - Plantar to the left first metatarsal head is a very panful hyperkeratotic lesion that measures 1.1 cm in diameter. There is a second lesion plantar to the fifth plantarflex metatarsal head which also measures 1.1 cm in diameter. These lesions have become so painful that the patient is now having difficulty walking wearing shoes or even doing gardening. The first and fifth metatarsal heads are plantarflexed. Vibratory sensation appears to be absent. Dorsal pedal pulses are nonpalpable. Varicose veins are visible to the skin on the patient's feet that are very thin, almost transparent. The medial aspect of the left great toenail has dried blood under the nail. The nail itself is very opaque, loose from the nailbed almost rotten, opaque, discolored, hypertrophic. All of the patient's toenails are elongated and discolored and opaque as well. There is dried blood under the medial aspect of the left great toenail.
A - 1. Painful feet.
2. Painful plantar lesions.
3. Painful benign lesions.
4. Plantarflex metatarsal heads.
P - Aseptic technique was used and the benign lesions were excised from the area plantar to the first and fifth left plantarflexed metatarsal heads. The medial aspect of the left great toenail was excised where the portion of the nail matrix blood loss was less than 5 cc. Hemostasis was achieved. The wounds were dressed with Neosporin ointment and absorbent dressing. The patient's remaining nine toenails required manual as well as electric debridement. "How to Care for Your Toe after Ingrown Nail Surgery" pamphlet was given to the patient with instructions to soak her foot in warm Epsom salts water b.i.d and to use no hydrogen peroxide and to use no Band-Aid on the toe, but to use an absorbent gauze dressing and a small amount of Neosporin ointment. I have also prescribed for the patient accommodative prescription diabetic orthotics and shoes within the combination for the first and fifth left metatarsal heads. She is to follow up at this office in one week for a recheck visit.
Keywords: soap / chart / progress notes, painful left foot, lesions, plantar, metatarsal head, hyperkeratotic lesion, toenail, nail matrix, metatarsal, metatarsal heads, foot, painful,