Complete Note
Share
Tweet
Cite
Click to rate this SOAPnote
[Total: 1 Average: 5]
approximately 14 views in the 30 days since someone like you supported this project.
[textarea default="HISTORY: No history of previous leg or foot ulcer. No history of lower limb amputation or surgery. No prior angioplasty, stent, or leg bypass surgery. No history of a foot wound requiring more than 3 weeks to heal. No history of smoking or nicotine use. No burning or tingling in legs or feet. No leg or foot pain with activity or at rest. No changes in skin color, or skin lesions. No loss of lower extremity sensation. "]
[textarea default="EXAM: Nails are not discolored, ingrown, or elongated. There are not signs of fungal infection. No discolored and/or hypertrophic skin lesions, calluses, or corns. No open wounds or fissures. No interdigital maceration. Responsive to the Ipswich Touch Test (Clinician rests his or her index finger on the tip of the first, third, and fifth toes and asks the patient to indicate when he or she feels something). Full range of motion of the joints. No obvious deformities. Midfoot is not hot, red, or inflamed. Hair growth on the foot dorsum or lower limb is normal. Dorsalis pedis and posterior tibial pulses are palpable. There is no temperature difference between the calves and feet, or between the left and right foot. "]
[textarea default="ASSESSMENT: Normal Foot Exam"]
[textarea default="PLAN: Patient instructed to (daily) visually examine both feet, including soles and between toes. Keep feet dry by regularly changing shoes and socks; dry feet after baths or exercise. Report any new lesions, discolorations, or swelling to a health care professional. "]
[checkbox memo="display/hide references" name="footnotes" value=""][conditional field="footnotes" condition="(footnotes).is('')"]
reference: [link url="http://www.ncbi.nlm.nih.gov/pubmed/25362495" memo="#1"] Miller JD, Carter E, Shih J, Giovinco NA, Boulton AJ, Mills JL, Armstrong DG. How to do a 3-minute diabetic foot exam. J Fam Pract. 2014 Nov;63(11):646-56. Erratum in: J Fam Pract. 2015 Aug;64(8):452. PMID: 25362495.
[/conditional]




display/hide references

Result - Copy and paste this output:

Send Feedback for this SOAPnote

Your email address will not be published.

More SOAPnotes by this Author: