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Subjective:
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|
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Patients symptom
• • •
|
|
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Chief Complaint
• • •
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Side (foot)
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Patient denies
• • •
|
Patient has had
• • •
|
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Duration
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Onset
• • •
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Nature
• • •
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Precipitating event
• • •
|
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Previous episodes, denies
|
Previous episodes
|
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Previous Treatment
• • •
|
|
|
PMH
|
|
|
Objective:
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|
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The patient is
• • •
|
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Vascular: Dorsalis pedis pulses (right)
• • •
|
Vascular: Dorsalis pedis pulses (left)
• • •
|
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Posterior tibial pulses (right)
• • •
|
Posterior tibial pulses (left)
• • •
|
|
Digital hair growth (right)
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Digital hair growth (left)
|
|
CFT with the leg elevated (right)
• • •
|
CFT with the leg elevated (left)
• • •
|
|
There is no evidence of ischemic skin changes
|
Temperature, Texture, Turgor is
• • •
|
|
b/l
|
|
|
Musculoskeletal: Normal range of motion
• • •
|
Neuro: Exam
• • •
|
|
Derm
• • •
|
Adequate fatpadding-inferior aspect of each heel
|
|
Ulceration observed on
• • •
|
|
|
Aspect of the toe
• • •
|
Foot
|
|
Additional Comments
|
|
|
Type
• • •
|
Size (length)
|
|
Size (width)
|
|
|
Base: Ulceration extends
• • •
|
Granular tissue
|
|
Fibrous tissue
|
Necrotic tissue
|
|
Drainage
• • •
|
Surrounding Area
• • •
|
|
Grade
|
|
|
Assessment:
|
|
|
Ulcer
|
Ulcer
|
|
Plan:
|
|
|
Plan: Office Visit - New Patient (Level 2)
|
Evaluation and management performed
|
|
Comments
|
|
|
Debridement of ulceration
• • •
|
Wound dressing of
• • •
|
|
Pt to do daily dressing changes at home with
• • •
|
Return appointment
|
