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Original Question

EMERGENCY DEPARTMENT Sex: Female AGE: 55 DOS: 1/1/20XX CC: Heel Pain HISTORY OF PRESENT ILLNESS: The patient is a female who presents to the emergency department with concerns over heel pain to the right heel noted over the last 6 weeks. The pain to the heel has increased today. She finds it difficult to walk. Sleeping has been a problem. She is not sure if it is positional or discomfort when the sole of the foot is palpated or pressure is placed upon the foot in that area. There has been no swelling. No injury. No numbness and tingling to the extremity. She attempts to change positions frequently during the day, and she rotates the shoes that she wears to work. She does work 12 hour shifts, standing a significant part during her workday. There is no prior history to this heel. PAST MEDICAL HISTORY: Negative. FAMILY HISTORY: Positive for cancer, heart disease, mesothelioma. SOCIAL HISTORY: Positive for alcohol use. She is employed at the hospital. REVIEW OF SYSTEMS: The rest of the review of systems per HPI is otherwise negative. MEDICATIONS: Ibuprofen. ALLERGIES: CODEINE AND SULFA. PHYSICAL EXAMINATION: VITAL SIGNS: Temperature 98, pulse 92, respirations 18, blood pressure 108/61, oxygen saturation is 98% on room air showing good oxygenation. GENERAL: Alert and oriented x3, well-nourished and developed female in no apparent distress. SKIN: Pink, warm, and dry. The sole of the foot to the right heel does not show tenderness or swelling. No undue redness. It does not appear to be cellulitis. There is no inflammatory process visualized. The skin is intact. MS: Good range of motion is noted. Toes wiggle; dorsiflexion is intact as is inversion and eversion. Palpation of the metatarsals does not elicit discomfort. There is point tenderness to the sole of the foot more laterally than mid center as the site of tenderness. The Achilles tendon does not appear to be affected. There is no malleolar region discomfort. NEURO: Grossly intact with normal sensation of the distal extremity. Capillary refill less than 3 seconds and pedal pulses are palpated and strong. EMERGENCY DEPARTMENT COURSE: ED plan of care included x-rays of the heel. There is normal joint space alignment. Bony disturbances include a heel spur and no tissue edema. As I palpate her heel, I do not see that the bone spur is in relation to the area of tenderness. The bone spur, per x-ray, appears to be old and I do not believe that it is associated with the discomfort that she has today. I believe that she is suffering from plantar fasciitis. She has an appointment with Dr. Jones in 1 week. My plan will be to place her in a splint to be worn only during sleep and off during the day. Orthotics will be decided by Dr. Jones. She has received a prescription for Naprosyn and Vicodin. She currently is stable. She understands the plan of care. DIAGNOSTIC IMPRESSION: Plantar fasciitis.

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