Initial Podiatry Progress Note

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Initial Podiatry Progress Note

Vanessa Nieves, DPM

Date of Service:______Facility:______Room #:______

Patient:______SEX:___ Attending:______DLV:______

Date of Birth:______Allergies:______

Responsive Capacity: r Good r Fair r Poor r Combative Place of service: r Bedside rWheelchair Patient is r ambulatory r Bedridden

Clinical Findings
Vascular Exam R L
Dorsalis Pedis /4 /4
Posterior Tibialis /4 /4
Popliteal Pulse /4 /4
Capillary Filling Time _____sec ____sec
Varicosities r Foot rFoot
r Ankle rAnkle
r Leg rLeg
Temp. Gradient r WNL r WNL
INC/DEC INC/DEC
Skin Temperature r WNL r WNL
Cool/Hot Cool/Hot
Edema r Yes r NO r Yes r No
(Location) ______
Hair growth r Yes r NO rYes r No
r Diminished r Diminished
Dependant Rubor/Pallor/Cyanosis?
r Yes r No rYes r NO

Neurological Exam

DTR’s r Deferred r Deferred
(patellar/ankle) /5 /5 /5 /5
Sharp/Dull r WNL r WNL
DEC./ INC. DEC. / INC.
Hemipariesis rYes r No r Yes r No
Foot brace worn? rYes r No r Yes r No
Ambulatory? rYes r No r Yes r No
Babinsky Sign (+) (-) (+) (-)
PODIATRIC DIAGNOSIS (ES)
1)______2) ______
3)______4) ______/

Orthopedic Exam R L

Hammer Toes? 1 2 3 4 5 1 2 3 4 5
Clavi/Callous 1 2 3 4 5 1 2 3 4 5
Bunion? r Yes r No r Yes r No
Overall ROM: r WNL r WNL
r Decreased r Decreased
Crepitus/effusion? r Yes r No r Yes r No
Amputation? TOE___ BKA___ TOE___ BKA___
TMA___ AKA___ TMA___ AKA___
Muscle pw /15 Muscle pw /15
Foot Type Cavus/Planus/ Cavus/Planus/
average average

Dermatological Exam

Skin Color r Normal r Cyanotic rR rL rB
r Ruborous r Pallor
Texture r Normal r Thin rR rL rB
Atrophic

Skin Lesions

r Hyperkeratoses ______
r Preulcerative Area______
r Ulcerations______
r Other______

Interspaces R L

r Clear 1 2 3 4 5 1 2 3 4 5
r Macerated 1 2 3 4 5 1 2 3 4 5

Nails

1 / 2 / 3 / 4 / 5 / 1 / 2 / 3 / 4 / 5
5)______/ r Normal
Treatment Plan: / r Hypertrophic Dystrophic
r Discoloration
r Thickening
r Thick,Yellow, Mycotic
r Onochocryptosis
r Lateral nail border
r Medial Nail Border
r Both Borders
r Drainage
r Evidence of clubbing
r Evidence of pitting

______Recall Visit: r 30 days r 60 days r Next Visit

Podiatrist’s Signature Date

C/O “______”

/podiatry/Podiatry Progress Note Oct.98