|
Subjective:
|
|
|
CC: Say date last seen.
|
comment
|
|
PMH:
|
Family, Social history
|
|
Past Surgical hx.:
|
|
|
Vascular:
|
Ankle edema?
|
|
Dorsalis pedis pulses are- Right
|
left
|
|
tibial pulses are graded at- right
|
Left
|
|
Digital hair growth is- Right
|
Left
|
|
CFT with the leg elevated- Right
|
Left
|
|
Derm:
|
Evidence of ischemic skin changes?
|
|
Turgor
|
added stuff
|
|
Neuro:
|
Balance issues.
|
|
Patellar tendon reflex is- Left
|
Right
|
|
Achilles tendon reflex is- Left
|
right
|
|
Babinski reflex is- Left
|
Right Foot
|
|
5.07 monofilament test displayed
|
|
|
Sharp-dull sensation- Left Foot
|
Right
|
|
Soft touch sensation (B)
|
added neuro findings
|
|
Vibratory sensation is- Left Foot
|
Right
|
|
Musculo/Skeletal:
|
|
|
M/S
• • •
|
additions
|
|
Assessment:
|
|
|
Diabetes
• • •
|
additions
|
|
Plan
|
|
|
Plan:
• • •
|
Comments
|
|
Diabetic foot education performed.
|
|
|
advised to have diabetic foot exam annually
|
picture
|
|
diabetic shoe eval.
|
|
|
Shoe style, color,size and width?
|
|
