SOAP / Chart / Progress Notes
Sample Name: Plantar Fasciitis
Description: A 44-year-old, 250-pound male presents with extreme pain in his left heel.
(Medical Transcription Sample Report)
S - A 44-year-old, 250-pound male presents with extreme pain in his left heel. This is his chief complaint. He says that he has had this pain for about two weeks. He works on concrete floors. He says that in the mornings when he gets up or after sitting, he has extreme pain and great difficulty in walking. He also has a macular blotching of skin on his arms, face, legs, feet and the rest of his body that he says is a pigment disorder that he has had since he was 17 years old. He also has redness and infection of the right toes.
O - The patient apparently has a pigmentation disorder, which may or may not change with time, on his arms, legs and other parts of his body, including his face. He has an erythematous moccasin-pattern tinea pedis of the plantar aspects of both feet. He has redness of the right toes 2, 3 and 4. Extreme exquisite pain can be produced by direct pressure on the plantar aspect of his left heel.
A - 1. Plantar fasciitis.
2. Tinea pedis. There is the possibility this patient has tinea purpura.
P - Injection into the medial aspect of the left heel using 1.0 cc of Celestone, Soluspan. The left foot and ankle were strapped and taped. The patient is instructed to keep the tape dry and on his foot for at least one week and that, if he decides to wear plastic bag over the foot, he is to be very careful and not slide up and fall down on a wet bathroom floor. Rx: Diflucan 200 mg #30 one daily with food, out-of-work excuse 10 days. Follow up in this clinic in one week.
Keywords: soap / chart / progress notes, plantar fasciitis, tinea pedis, tinea purpura, heel, fasciitis, plantar,