SOAP NOTE PLANTAR FASCIITIS Name: SC Date: 09/25/16 Time: 10:40 Age: 29 Sex: Female SUBJECTIVE CC: “ "I have been seen by Ortho last week and diagnosed with plantar fasciitis but still having severe pain in my right foot" HPI: SC is a 29 year old female who presents to the office today with complaints of pain in the bottom of her right foot near the heel after 1 week of being diagnosed with plantar fasciitis. SC reports the pain is worse in the morning with the first few steps after awakening, and after standing or sitting for long periods. According to the patient the pain started about 2 weeks ago and she was evaluated by orthopedic doctor last week but she still having pain since then. SC is a special education teacher and is on her feet the majority of the day. She has been taking Mobic 15 mg daily as prescribed by Ortho to control the pain which provides minimal relief. Medications: Singulair 10 mg PO daily Allergies Atorvastatin 20 mg PO daily High Cholesterol Omeprazole 10 mg PO daily GERD Mobic 15 mg PO daily x 14 days Plantar Fasciitis PMH Allergies: NKDA. Pollen and dust mites. Medication Intolerances: None Chronic Illnesses/Major traumas Childhood: No significant childhood illnesses or injuries. Adult: hyperlipidemia, GERD, seasonal allergies Social : Married. G1, P1, A0. Patient denies any further OBGYN issues. Works as a special aid teacher. Denies tobacco or drug use. Reports social alcohol use. Typically walks several times a week, but has been unable to lately d/t foot pain. Psychiatric: Patient denies feelings of sadness or depression. Immunizations: Currently up to date on immunizations. Tetanus 10/2014. Flu vaccine 2015. - Last mammogram: 01/2016 (normal) - Last pap: 04/2016 (normal), no hx of abnormal paps - Last dental exam: 2015 Hospitalizations/Surgeries Surgical : appendectomy (2000) Family History Mother: HTN, Hyperlipidemia
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