HITNOTS HEALTH PODIATRY CENTER 1234 ABC Street Charlotte, NC 29707

Transcription

1 Patient Name Macy P. Date of Visit - 04/29/2018 Date of Birth- 02/12/1969 Medical Record Check-In Time 9:15 am Insurance - Commercial Preferred Language - English. Medical Assistant Celeste T., CMA Patient identity verified via palm print. Chief Complaint Patient is here for post-op visit #3 for bunionectomy, right. History HPI - Patient is 30+ days post-op. Patient states she is able to wear a regular shoe. Social History Works full-time in a banking office. Marital Status Married Caffeine Intake 3 cups of coffee per day Smoking Status No smoking Smokeless Tobacco No Alcohol Use Social Drinker Drug Use No Physical Activity Patient works out 3 times a week.

2 Family History Both parents suffered with heart disease Past Medical History Patient has been healthy throughout her life. Past Surgical History T&A, Hysterectomy, Three vaginal deliveries. Review of Systems Eyes Wears reading glasses. Musculoskeletal Back problems Dermatologic No skin discoloration. No evidence of venous stasis, cellulitis or rash. Current Medications Venlafaxine 75 mg capsule extended release 24 hr. Allergies NKA Physical Exam Height Weight lbs. BMI Flag: Obese

3 Vitals Temp 98.7 F. Blood Pressure 140/90 mmhg. The vitals were recorded by Celeste T., C M.A., Medical Assistant at HITNOTS Health at 9:18 am.on 04/29/2018 Apparent State of Health Patient appears to be in generally good health. The patient is awake, alert, understands questions and responds appropriately. Cardiovascular The left dorsalis pedis pulse is 2+ brisk normal. The right dorsalis pedis pulse is 2+ brisk normal. Capillary filling time of the left great toe left foot is 2 seconds. Capillary filling time of the right great toe is 2 seconds. Musculoskeletal The anterior tibialis muscle strength is +5/5 bilaterally. The posterior tibial muscle strength is +5/5 bilaterally. Foot Assessment There is a hallux valgus noted bilaterally. Digits Both Feet There is a rotation deformity at the 5 th toe noted bilaterally - bunion. Tailor Neurologic Reflexes There is no ankle clonus bilaterally. Sensory Proprioception is WNL. Assessment and Follow-up Plan (for each diagnosis)- Post-op localized soft tissue edema in right foot Post-op pain in right foot.

4 Hallux Valgus, acquired, right foot. 1 st and 5 th metatarsal, right foot. This is patient s 3rd postop visit. New Medications and Refills Ordered Today Date Started Medication Name & Dosage Directions None Procedures Today Post-op Follow-up visit #3 X-ray Exam of Foot 3 Views X-ray Findings I noted good alignment of the right 1 st. metatarsal. Noted healing. Noted soft tissue edema. Care Today I reviewed patient s x-rays with her in detail. I note good alignment of the right 1 st metatarsal. I instructed patient that I will let her drive. I discussed the type of shoe that she is wearing today is not good. A less restrictive shoe with a wide base is recommended.

5 General Counseling I have discussed the findings of this exam with the patient. A schedule for future care needs was explained. Patient verbalized understanding of these instructions at this time. If there are any questions patient should call the office. Patient is instructed to return to the office in 4 weeks. The patient verbalized understanding of the treatment plan. Risks, benefits, precautions and side effects were discussed and the patient was given an opportunity to ask questions. Electronically signed by Carl M. DPM on 04/29/2018 at 10:09 am. Janice C., CMA, Medical Scribe

6 OFFICE VISIT TYPE PODIATRY PATIENT ENCOUNTER FORM NEW PATIENT Problem Focused Expanded PF Detailed Comprehensive Mod Comprehensive - High ESTABLISHED PATIENT Minimum Problem Focused Expanded PF Detailed Comprehensive Post-Op Follow-up DIAGNOSES Achilles Tendinitis Athlete s Foot Blisters, Foot Bone Spur Bunionette, Right Callus Corns Diabetic Foot Care

7 DIAGNOSES DSAP Edema, Foot Foot Pain, Left Foot Pain, Right Fungal Toenails Gout Hallux Valgus, left Hallux Valgus, right Hammertoes Ingrown Toenail Osteoarthritis Pain, Heel Plantar Fasciitis Plantar Warts Rheumatoid Arthritis RADIOLOGY Radiology, Ankle, 2 Views Radiology, Ankle 3 Views Radiology, Foot 2 Views Radiology, Foot 3 Views Radiology, Calcaneus, Views Radiology, Toes, 2 Views 73660

8 This medical record information is being used for study and is totally fictitious. Any similarity to a real person, living or dead, is incidental. The medical content of this record may not be totally clinically accurate, and therefore should not be used as an example for diagnosis or treatment.