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Feb 20, 2024





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SOAP NOTE Patient Name: Rick Rodriguez PCP: Anderson Phipps, MD Date of Visit: August 6, 2023 Sex/Age: M/45 DOB: March 6, 1978 Patient ID: 000196 SUBJECTIVE: The patient presents today for recheck of problems with his feet. He likes the diabetic shoes dispensed to him in our office in Nashville on 15 July. Patient states that he can walk extensively without his feet becoming tired and painful. He has long toenails. Patient presents with dry necrotic scab involving the interior aspect of the crest to the tibia of the right lower extremity. PAST MEDICATIONS AND ALLERGIES REVIEW: He has Type 2 diabetes mellitus, heart disease, asthma, osteoarthritis, hyperlipidemia, depression, hypothyroidism, low testosterone, bipolar disorder, chronic back pain, migraine headaches. OBJECTIVE: The patient is alert, responsive 45-year-old Hispanic male who presents with distention and enlargement of the thoracic cavity. Lower Extremity integument. Toenails are long and thick. Hyperkeratosis on inferior aspect of the heels bilaterally. Dry necrotic scab measuring at 6 x 3 mm at the interior middle aspect of the right tibia. VASCULAR: Pedal pulses +2/4 bilaterally. NEUROLOGICAL: Semmes-Weinstein sensation is decreased involving plantar aspect of the jallux bilaterally. MUSCUALSKELETAL: No pain elicited upon palpation or compression of the structures of the lower extremities bilaterally. ASSESSMENT: 1. Onychogryphosis of the toenails. 2. Hyperkeratosis of the feet bilaterally. 3. Type 2 Diabetes Mellitus 4. Mild Peripheral Neuropathy 5. Traumatic Abrasion 6. Healing of the right leg (Continued) Mallory Johnson 12-1
SOAP NOTE Page 2 Patient Name: Rick Rodriguez PCP: Anderson Phipps, MD Date of Visit: August 6, 2023 Patient ID: 000196 PLAN 1.Diabetic footwear. The patient is to wear Dr. Comfort diabetic footwear which was dispensed to him in our office in Nashville. 2. Debridement of hyperkeratosis. 3. The patient wants to confer with doctor first. 4. When the traumatic abrasion occurred on the right leg there was extensive bleeding. The patient believes that it may be necessary to adjust his daily dosage of Aspirin. 5. Patient is to return in five weeks. ______________________________ Donna Sherwood DPM, Podiatry DS:MJ D: 11/28/2023 T: 11/28/2023 C: Anderson Phipps, MD, Family Medicine/Geriatrics Mallory Johnson 12-1
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