10 Documentation
Patient presents with complaints of left foot pain. Onset of pain is described as (acute, subacute, chronic), with duration of (number) days, weeks, months, years. Location of pain is specified as (dorsal, plantar, medial, lateral, anterior, posterior) aspect of the foot, involving (forefoot, midfoot, hindfoot) region. Patient reports the pain quality as (sharp, dull, aching, burning, throbbing, radiating). Pain severity is reported as (mild, moderate, severe) on a scale of 0-10, currently rated at (number). Aggravating factors include (weight-bearing, ambulation, rest, specific movements, footwear). Alleviating factors include (rest, elevation, ice, over-the-counter medications such as ibuprofen or acetaminophen). Patient denies any history of trauma, injury, or known medical conditions contributing to the left foot pain. Physical examination reveals (tenderness to palpation, edema, erythema, warmth, deformity, limited range of motion, crepitus) in the (specific location) of the left foot. Neurovascular assessment of the left foot reveals (intact or diminished) sensation, motor function, and capillary refill. Differential diagnoses include plantar fasciitis, metatarsalgia, Morton's neuroma, stress fracture, tendonitis, arthritis, and peripheral neuropathy. Assessment: Left foot pain, etiology to be determined. Plan: Recommend (radiographs, MRI, CT scan, blood work) to further evaluate the cause of the left foot pain. Prescribe (NSAIDs, pain medication, orthotics, physical therapy referral) for symptomatic relief. Patient education provided regarding activity modification, ice, and elevation. Follow-up scheduled in (number) weeks to reassess symptoms and discuss further management options.