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Sample Plantar Fasciitis Initial Visit TemplateDate of Service: Patient Name: D.O.B Subjective (Chief Complaint)Patient presents to the office today with pain and swelling on her right heel and arch area. Patient states that the area has been painful for several weeks especially while walking and with her first steps in the morning. Patient does not recall any injury and has not experienced relief with rest or by changing shoegear. Medication HistoryLisinopril 40 mg tablet Atorvastatin 40 mg tablet AllergiesNKDASocial History TobaccoFormer smokerAlcohol UseSocial Medical HistoryHypertensionHigh CholesterolSurgical HistoryAppendectomy 1998Family HistoryDiabetesHypertensionHeart Disease Review of Systems: Constitutional: Denied: Chills, Fever, Fatigue, Weakness, Weight Gain, Weight LossGood General HealthENT:EarsDenied: Discharge, Bleeding, Infection, ObstructionNoseDenied: Bleeding Gums, Post Nasal Drip, Dry MouthThroatDenied: Lumps, Tenderness, Swollen Glands, Difficulty SwallowingRespiratory: Denied: Asthma, Cough, Wheezing, Bronchitis, Shortness of BreathCardiovascular:Reported: High Blood PressureDenied: Chest Pain, Varicose Veins, Heart Murmur, PalpationsGastrointestinal:Reported: Occasional indigestion Denied: Constipation, Diarrhea, Rectal Bleeding, Loss of AppetiteMusculoskeletal:Reported: Foot PainDenied: Hip Pain, Knee Pain, Neck Pain, Back Problems, Muscle Cramps, Weakness, Joint SwellingPsychiatric: Denied: Anxiety, Depression, Disorientation, Memory LossSkin: Denied: Eczema, Itching, Warts, Dryness, Hives, Hair LossNeurological:Denied: Burning, Dizziness, Fainting, Head Injury, NumbnessEndocrine: Denied: Excessive Urination, Thirst, Thyroid, Heat or Cold Intolerance Hematologic:Denied: Anemia, Bleeding Easily, Blood Clots, Swollen, PhlebitisAllergic/Immunologic:Denied: Hives, Itchy Eyes, Itchy Nose, Runny Nose, SneezingGenitourinary:Denied: Kidney Disease, Blood in Urine, Burning, Excessive UrinationEye:Denied: Blurred Vision, Cataracts, Contacts, Eyeglasses, GlaucomaObjective: Vital Signs: Blood Pressure: 130/82 Weight: 150lbs. Height: 65” BMI: 24.2 Flag: NormalPhysical Exam: Constitutional: The patient is awake, alert, well developed, well nourished and well groomed.Cardiovascular lower extremity exam: Dorsalis pedis pulse left and right are palpable. Posterior tibial pulse left and right are palpable. Pedal hair growth is absent. Skin temperature is normothermic bilaterally. Edema is mildly present in the right heel/arch area. Musculoskeletal: Strength is 5/5 bilaterally. Moderate pain with palpation to the medical calcaneal tubercle, medial band origin of the right plantar fascia. No pain to palpation to the bilateral posterior aspect of the calcaneus, Achilles tendon. Dermatologic: Toenails are slightly thickened, dystrophic, yellow, positive onycholysis to 1, 2 right foot and 1-5 left. Nails are slightly incurvated. Neurologic: The deep tendon reflexes of the lower extremities are symmetrical and are graded at 2/4. Plantar reflexes (Rabinski) reveals toes are downgoing and there is no ankle clonus. Sensory testing of the lower extremities for sharp/dull sensation, position, vibration and monofilament sensation is in tact. There is no evidence of posterior tibial, superficial peroneal, or sural nerve pathology. There is no evidence of intermetatarsal neuroma bilaterally. AssessmentPossible Diagnosis (es): Plantar Fascial Fibromatosis M72.2Calcaneal Spur, Right Foot M7731Contracture M24.576Pain (RT) M25.571 Plan (Procedure Coding) 99203 (Office Visit/Outpatient Visit New)73630 (X-Ray Exam of Foot 3 views) RTX-rays showed no evidence of fracture, dislocation, periostitis, or gas in the tissue. Cancaneal spur is shown posteriorly and plantarly right foot.L4397 (Posterior Nightsplint) RTA plastic pre-fabricated RIGHT static ankle-foot orthosis was dispensed and fitted at this visit. The device will be utilized for the next six to eight weeks. Due to the severe pain in the heel when first weight bearing and throughout the day, with diagnosis of plantar fasciitis and related symptoms, this is medically necessary for the treatment. The function of this device is to serve as an anti-contracture device of the plantar fascia and Achilles tendon and to restrict and limit motion and help reduce excessive stress and strain to the plantar fascia and Achilles tendon. It is being utilized to prevent the plantar contracture of the Achilles tendon and its distal terminus, the plantar fascia, and serve to decrease the stress of the fibers of the Achilles tendon insertional effect of tension in the proximal fibers of the plantar fascia via its periosteal attachment. A written prescription for the dispensing of this device has been provided. The goals of this therapy are to: 1.) To reduce the pain and symptoms of post-static dyskinesia. 2.) Prevent non-weightbearing contracture of the Achilles tendon. 3.) Provide static stretch of the Achilles tendon. 4.) Reduce plantar fasciitis. The goals and function of this device was explained in detail to the patient. The patient states that the device is comfortable when applied at this time. The patient was shown and told in detail how to properly wear and care for the device. The patient was able to apply the device properly and to ambulate without distress. The device was then dispensed and was suitable for the condition and not substandard. No guarantees were given and precautions were reviewed. Written instructions and warranty information was given and the 30 DME Supplier Standards form was offered to the patient. All questions were answered.20600 (or preferred injection code) with J Code (Injection RT) (need NDC# for claim purposes)Under asceptic conditions using a 1 ? inch needle, 25 gauge 3 cc. syringe, an infiltration of 1cc. of 2% plain xylocaine and 1cc. of Dexamethasone Sodium Phosphate was made at the right arch area joint to reduce pain and inflammation. 29540 (Strapping RT) with -59 modifier An application of dispersive padding was applied to the affected area. Patient was instructed to ice the area later on today to reduce any sensitivity. Care Plan: Discussed conservative and surgical treatment options. Recommended the use of Nightsplint during times of rest and prior to ambulation. Patient was instructed to, no barefoot walking, rest, ice, elevation, use of Prescription anti-inflammatory (Rx 800 mg Ibuprofen t.i.d. sent electronically), and topical analgesics to relieve pain. Custom Orthotics were discussed during today’s visit and will be revisited upon follow up visit (to be scheduled in 2 weeks). ................
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