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Subjective:
|
|
|
Status post
• • •
|
Status post
|
|
Side (foot)
|
Scheduled to be performed at
• • •
|
|
PMH
|
|
|
Objective:
|
|
|
Dorsalis pedis pulses are (right)
|
Dorsalis pedis pulses are (left)
|
|
Posterior tibial pulses are graded at (right)
|
Posterior tibial pulses are graded at (left)
|
|
Digital hair growth is (right)
|
Digital hair growth is (left)
|
|
CFT with leg elevated at distal hallux (right)
|
CFT with leg elevated at distal hallux (left)
|
|
There is no evidence of ischemic skin changes
|
Temperature, Texture, Turgor is
• • •
|
|
Bunion exam right Bunion exam Left
|
Bunion exam right Bunion exam Left
|
|
|
|
|
Assessment:
|
|
|
bunion/HAV/MPA
• • •
|
plantarflex/long metatarsal
|
|
hammertoe
|
neuroma
|
|
Side (foot)
|
|
|
Plan:
|
|
|
Office Visit - Est. Patient (Level 3)
|
|
|
Discussed with
• • •
|
Discussed
• • •
|
|
Proposed surgical procedure is
• • •
|
Side (foot)
|
|
Discussed with
• • •
|
course
• • •
|
|
Discussed
• • •
|
All questions were answered and understood
|
|
Informed consent was obtained
|
Patient
• • •
|
|
Pt was also given pre-op H&P form & lab orders
|
Patient was given postop pain Rx for
• • •
|
|
one q
• • •
|
hours prn pain
|
|
Disp#
• • •
|
|
|
|
|
|
Return appointment after the surgery
|
For
• • •
|
