1. PODIATRIC
PRACTICE
TEMPLATES
Brooks Foot & Ankle
Associates
Medicine and Surgery of the
Foot and Ankle
BRADIE BRITT
JESSICA VERVOORT
KENNETH OMS
SUZANNE JEAN-BAPTISTE
2201 E Nine Mile Rd Pensacola, FL 32514
Telephone : 850-479-6250
Fax : 850-479-6247
Email : info@FeetAreNeat.com

2. 1
Contents
List of Figures.....................................................................................................................................6
Introduction.......................................................................................................................................8
Dermatology......................................................................................................................................8
Benign Neoplasm/Lesion of uncertain behavior................................................................................8
Dermatitis - Established Patient- Biopsy - AFC................................................................................10
Dermatological Exam Normal ........................................................................................................12
Foreign Body Health & Physical......................................................................................................12
Hyperkeratosis- Initial...................................................................................................................15
Hyperkeratosis - Follow-up............................................................................................................18
Hyperkeratosis Debridement.........................................................................................................19
Incision & Drainage – Established Patient.......................................................................................19
Incision & Drainage –NewPatient..................................................................................................20
Ingrown Nail – Follow-up...............................................................................................................22
Kissing corn ..................................................................................................................................23
Lesion Description ........................................................................................................................25
Nail Avulsion - Initial .....................................................................................................................25
Nail Avulsion - Follow-up...............................................................................................................27
Onychomycosis - Established Patient.............................................................................................27
Onychomycosis - New Patient........................................................................................................29
Phenol and Alcohol Matrixectomy .................................................................................................31
Phenol and Alcohol Matrixectomy – Established Patient.................................................................32
Phenol and Alcohol Matrixectomy – New Patient...........................................................................33
Partial Nail Avulsion – New Patient................................................................................................35
Partially AvulsedNail.....................................................................................................................37
Pigmented Lesion .........................................................................................................................39
PinPointe - Initial ..........................................................................................................................41
PinPointe - Follow-up....................................................................................................................44
Ulceration - Initial Visit..................................................................................................................45
Ulceration - Follow-up...................................................................................................................47
Ulceration of Toe - Initial...............................................................................................................48
Verruca - Initial.............................................................................................................................51
Verruca - Follow-up.......................................................................................................................53

3. 2
Musculoskeletal ...............................................................................................................................53
Achilles Tendonitis - Initial.............................................................................................................53
Achilles Tendonitis - Follow-up......................................................................................................57
Achilles Wrap ...............................................................................................................................58
Ankle Exam...................................................................................................................................58
Ankle instability/Sprain - Initial......................................................................................................59
Ankle Sprain.................................................................................................................................62
Aspiration.....................................................................................................................................63
Bunion Exam................................................................................................................................63
Bunion - Initial..............................................................................................................................64
Bunion - Follow-up........................................................................................................................65
Calcaneal Apophysitis - Initial ........................................................................................................66
Capsulitis - Initial...........................................................................................................................69
Capsulitis - Follow-up....................................................................................................................72
Charcot - AFO...............................................................................................................................72
Contusion Foot/Toe - Initial Visit....................................................................................................76
EPAT............................................................................................................................................78
ETOH Injection..............................................................................................................................79
ETOH Injection..............................................................................................................................80
Excision Foreign Body....................................................................................................................80
Fracture - Initial Visit.....................................................................................................................82
Fracture - Follow-upVisit..............................................................................................................85
Gait Analysis.................................................................................................................................85
Gout - Initial Visit..........................................................................................................................86
Gout - Follow-UpVisit...................................................................................................................88
Hallux Rigidus - Initial Visit.............................................................................................................89
Hallux Rigidus – Follow-up - Steroid Injection .................................................................................92
Joint Injection...............................................................................................................................93
Hallux Valgus................................................................................................................................93
Hammertoe - Initial Visit...............................................................................................................94
Hammertoe - Initial Visit- Arthroplasty..........................................................................................97
Hammertoe – Follow-up.............................................................................................................. 100
Heel Exam - Ortho Exam.............................................................................................................. 101

4. 3
Joint Injection............................................................................................................................. 101
Osteoarthritis - Initial Visit........................................................................................................... 102
Osteoarthritis Follow-up.............................................................................................................. 104
Peroneal Tendonitis.................................................................................................................... 105
Pes Planus..................................................................................................................................107
Plantar Fasciitis - Initial Visit........................................................................................................111
Plantar Fasciitis - D/C.................................................................................................................. 114
Plantar Fasciitis - Follow-up - Steroid Injections ............................................................................ 115
Plantar Fasciitis - Follow-up - Surgery Recommended....................................................................117
Plantar Fibroma.......................................................................................................................... 118
Posterior Tibial Tendonitis - Initial Visit........................................................................................ 122
Posterior Tibial Tendonitis - Follow-up......................................................................................... 124
Sesamoiditis – Initial Visit............................................................................................................ 126
Sinus Tarsitis – New Patient......................................................................................................... 129
Tailor's Bunionette Deformity......................................................................................................132
Tarsal Tunnel Syndrome - Initial Visit............................................................................................ 134
Tarsal Tunnel Syndrome – Established Patient.............................................................................. 137
TineaPedis - Initial Visit............................................................................................................... 138
TineaPedis - Follow-up............................................................................................................... 140
Neurology......................................................................................................................................141
Neuroma - Initial Visit................................................................................................................. 141
Neuroma - Follow-up- Steroidinjection....................................................................................... 143
Neuroma - Follow-up- Surgery Recommended............................................................................. 144
Neuroma Discharge .................................................................................................................... 146
Neuropathy................................................................................................................................ 146
Surgery.......................................................................................................................................... 148
Amputation at the MPJ ............................................................................................................... 148
Apligraft Op report...................................................................................................................... 149
Arthroplasty Digit........................................................................................................................ 150
Biopsy epidermal Nerve density...................................................................................................151
Biopsy Lesion.............................................................................................................................. 153
Chilectomy.................................................................................................................................154
Informed Consent – Achilles Tendon Repair................................................................................. 157

5. 4
CRYOSURGERY - Neuroma........................................................................................................... 159
ENFD post op 1........................................................................................................................... 162
ENFD post op 2........................................................................................................................... 163
Exostectomy............................................................................................................................... 164
Exostectomy/Condylectomy of Toe op-report.............................................................................. 166
Exostosis Distal toe..................................................................................................................... 167
Flexor Tenotomy......................................................................................................................... 168
Metatarsal Ostectomy................................................................................................................. 169
Post-op Arhtrodesis .................................................................................................................... 171
Post-op Bunionectomy................................................................................................................ 172
Post-op Visit 3 ............................................................................................................................ 173
Post-op Visit 4 ............................................................................................................................ 173
Post-op Visit Follow-up............................................................................................................... 174
Post-op Visit Initial...................................................................................................................... 175
Pre-op Consent........................................................................................................................... 176
Pre-op Consent........................................................................................................................... 176
Removal of Painful Internal Fixation............................................................................................. 179
Silver Bunionectomy................................................................................................................... 182
Correspondence............................................................................................................................. 183
EPAT Customer Satisfaction Survey.............................................................................................. 183
Letter of Medical Necessity ......................................................................................................... 184
Letter of Medical Necessity - 64455 ............................................................................................. 185
Letter of Medical Necessity - Orthotics or Diabetic Insoles/Shoes.................................................. 185
Post-op Instructions.................................................................................................................... 186
Post-op Instructions - Matrixectomy............................................................................................ 189
Post-op Instructions - Verruca .....................................................................................................191
Durable Medical Equipment............................................................................................................ 192
AFO Prescription - Casting........................................................................................................... 192
AFO Prescription - Mini-templates............................................................................................... 192
AFO Dispensing........................................................................................................................... 192
AFO – Follow-up......................................................................................................................... 193
Aircast Ankle Brace..................................................................................................................... 194
Ankle Brace ................................................................................................................................ 195

6. 5
Dispensing Orthotics................................................................................................................... 196
Durable Medical Equipment Prescription ..................................................................................... 196
Leg Cast......................................................................................................................................197
Night Splint................................................................................................................................ 198
Non-pneumatic Walker............................................................................................................... 199
Non-pneumatic Walker for Bunion............................................................................................... 200
Orthotic Casting.......................................................................................................................... 200
Orthotic Follow-up...................................................................................................................... 202
Diabetic......................................................................................................................................... 204
Diabetic Neurological and Vascular Exam..................................................................................... 204
Diabetic Shoe Dispensal .............................................................................................................. 207

7. 6
List of Figures
Figure 1 - Benign Neoplasm on Left....................................................................................................10
Figure 2 – Dermatitis.........................................................................................................................12
Figure 3 - Screw Foot and Flip-Flop Sandal .........................................................................................15
Figure 4 - Healing Progression of Postoperative Ingrown Toenail.........................................................23
Figure 5 - Soft Kissing Corn................................................................................................................24
Figure 6 - Proximal subungual onychomycosis (arrow)........................................................................29
Figure 7 – Phenol portion of Matrixectomy........................................................................................35
Figure 8 - Lesion noted by patient after a training run while wearing joggers .......................................41
Figure 9 – Pinpoint laser producer.....................................................................................................43
Figure 10 – After application of Pinpoint............................................................................................44
Figure 11 - PinPointe Laser machine ..................................................................................................44
Figure 12 – Illustration of Ulcerated Foot...........................................................................................50
Figure 13 – Verruca Plantar Wart.......................................................................................................52
Figure 14 – Illustration of Achilles Tendonitis......................................................................................55
Figure 15 - AirHeel™ .........................................................................................................................56
Figure 16 - Aircast®...........................................................................................................................56
Figure 17 – Achilles Wrap..................................................................................................................58
Figure 18 – Bunion............................................................................................................................63
Figure 19 – Illustration describing Calcaneal Apophysitis.....................................................................69
Figure 20 – Capsulitis........................................................................................................................71
Figure 21 – Illustration of Normal Foot...............................................................................................75
Figure 22 - Illustration of Charcot Foot...............................................................................................76
Figure 23 - Patient presenting with Charcot Foot................................................................................76
Figure 24 - Contusion on Left Ankle ...................................................................................................78
Figure 25 – X-ray Examples of Foreign Body .......................................................................................81
Figure 26 – Antenor/Posterior View of Fibula Fracture........................................................................84
Figure 27 – Lateral and Antenor/Posterior View of Fibula Fracture ......................................................84
Figure 28 – Illustration of Gait Analysis ..............................................................................................86
Figure 29 - Gout in Left Foot..............................................................................................................89
Figure 30 –Photograph and X-ray of Hallux Rigidus deformity..............................................................92
Figure 31 - Illustration of Joint Injection.............................................................................................93
Figure 32 – Hallux Valgus of the Left Foot...........................................................................................94
Figure 33 – Before and After Demonstration of Hammertoe Surgery...................................................97
Figure 34 – X-Ray of Before andAfter Hammertoe Surgery .................................................................99
Figure 35 – Demonstration of a Joint Injection.................................................................................. 101
Figure 36 – Illustration of Osteoarthritis........................................................................................... 104
Figure 37 – Illustration of Peroneal Tendonitis.................................................................................. 107
Figure 38 – Illustration of Pes Planus................................................................................................ 110
Figure 39 – Patient with Pes Planus..................................................................................................110
Figure 40 – Illustration Plantar Fasciitis............................................................................................ 113
Figure 41 – Example of Insert.......................................................................................................... 115
Figure 42 – Patient Receiving Plantar Fascia Injection .......................................................................116
Figure 43 – Plantar Fasciitis Surgery.................................................................................................118

8. 7
Figure 44 – Patient Presenting with Plantar Fibroma......................................................................... 121
Figure 45 – Illustration about Plantar Fibroma.................................................................................. 121
Figure 46 – Illustration of Posterior Tibial Tendonitis ........................................................................124
Figure 47 – MRI of Sesamoiditis.......................................................................................................129
Figure 48 – X-Ray of Sinus Tarsitis....................................................................................................131
Figure 49 – Patient with Bunion and Tailor’s Bunion ......................................................................... 134
Figure 50 – Illustration of Tarsal Tunnel Syndrome............................................................................ 136
Figure 51 – Patient with Tinea Pedis ................................................................................................ 140
Figure 52 – Surgery of Neuroma......................................................................................................145
Figure 53 - X-ray of Internal Fixation................................................................................................ 181
Figure 54 - Example of Interval Fixation in place............................................................................... 181
Figure 55 - Example of Silver Bunionectomy..................................................................................... 183
Figure 56 - Aircast® Airsport™ Ankle Brace....................................................................................... 194
Figure 57 - DonJoy® RocketSoc™ Ankle Support Brace ......................................................................195
Figure 58 - Examples of Durable Medical Equipment......................................................................... 197
Figure 59 - Leg Cast on Left Foot......................................................................................................198
Figure 60 - DeRoyal® Night Splint.....................................................................................................199
Figure 61 - Aircast® Walking Boot....................................................................................................200
Figure 62 - Example of Clay Casting..................................................................................................201
Figure 63 - Example of plaster casting.............................................................................................. 201
Figure 64 - Examples of Orthotics ....................................................................................................203
Figure 65 - Before and After of Orthotics.......................................................................................... 203
Figure 66 - Display of Diabetic Shoes................................................................................................ 208

9. 8
Introduction
Group 2 isediting adocumentfora podiatrygroupin PensacolaFlorida.Thisdocumentwillbe usedby
the podiatricpractice to expeditetheirpatientrecordkeepingprocess.BrooksFoot& Ankle Associates
provideduswiththe templatestheyuse torecordpatientnotes.I visitedthe practice andcopied180
pagesof templatesoutof theirpatientrecordkeepingsoftware,TrakNet.Withthe helpof JoshuaBritt,
DPM, an associate of the practice,we were able toremove templateswhichdidnotneedediting.
The bracketsthat are usedthroughoutthe documentare neededsothatTrakNetcan create quickfill
optionswithinthe program.
Dermatology
Benign Neoplasm/Lesion of uncertain behavior
Patient: [Patient. Name] AccountNo:[Patient. AcctNo] Date:[Date]
Subjective:Patientpresentstodayc/oa[painful, non-painful] [lesion, growth,mole, wart, darkspot,
hard area, bleedinglesion] onthe [right, left][foot, ankle, leg].The areaof concernislocated[on,
between, onthe bottomof, beneath, ontopof, onthe right side of, onthe leftside of, onback of, on
frontof] the [the sulcusregion, the heel, the arch, the 1st MTPJ, the 2nd MTPJ, the 3rd MTPJ, the 4th
MTPJ, the 5th MTPJ, the bigtoe, the 2nd toe, the 3rd toe, the 4th toe, the 5th toe] [the foot, the ankle,
the heel, the leg].She [has, hasnot] noticedrecentchangesinthe area.She [has, doesnothave] a
personal historyof skincancer.She [has, hasnot] beenpreviouslydiagnosedwithandtreatedforother
formsof cancer.There [isa, isno] known familyhistoryof skincancer.
Objective:PMH,PSH,Medications:Unchangedsince lastvisit.The patient'sneurovascularstatusof
bilateral lowerextremityisunchangedsince lastvisit.
Dermatological:The lesionislocatedonthe [plantar, dorsal, medial, lateral, anterior, posterior] surface
of the [right, left] [foot,ankle, leg]. The lesionis[hyperkeratotic, hyperpigmented, hypopigmented,
raised, flat, red, blue, black, white, dark, papular, macular, isolated, singular, multilobulated, soft, firm,
freelymovable, fixed, intraepidermal, dermal, subcutaneous, deepfascial, osseous,chalky, blanchable,
non-blanchable, irregularborders, round,triangular, square, stellate, translucent, smooth, course, with
interruptedskinlines, wellcircumscribed, bleeding, crusted, escharotic, nucleated, ulcerated].After
inspection/debridementthe lesiondoesnotreveal anyverruca-type tissue,retainedforeignbodies,or
cardinal signsof infection. Otherwise,there isnoevidence of edema,erythema,ecchymosis,open
lesions,interdigitalmacerationorsignsof bacterial orfungal infectionof bilaterallowerextremities. No
varicosities,telangectasias,pigmentedlesionsorsignsof venousstasischangesbilateral lower
extremities. [Inadequate, Adequate] fatpaddingtothe inferioraspectof eachfootappreciated.
Musculoskeletal:[Pain,Nopain] isnotedtopalpationof the lesion.It[does, doesnot] appeartobe
intimatelyassociatedwithabonyprominence orfootdeformity.[Bunion, Hammertoe, Tailor'sbunion,
Metatarsal, Tarsal, Rearfoot] deformity[is, isnot] noted.

10. 9
Assessment: [Benignneoplasm, Deformedmetatarsal, Porokeratomadiscrita, Neoplasmof uncertain
behavior, Fibroma, Inclusioncyst, Foreignbodygranuloma, pyogenicgranuloma, verruca, IPK, Blue
nevus, Junctional nevus, Basal cell carcinoma, squamouscell carcinoma, possible melanoma]
Plan:
1) I have discussedthe treatmentoptionswiththe patientindetail,includingnon-surgical vs.surgical
care. Basedon myfindingsI recommended
[Non-surgical care, surgical management] of the condition.Irecommended[excisionof the entire lesion,
punchbiopsy, shave biopsy, excisionalbiopsy, withhistopathologicidentification.][Destruction of the
lesionwith][Serialdebridementandapplicationof Canthecur, liquidnitrogen, off-loading, periodic
paringof the lesion, modificationsof shoe inserts, dailyapplicationof aperture pads].
2) The patientdesires[non-surgical care, surgical management] forthe condition.Treatment today
consistedof [paringof the lesionfollowedbythe applicationof Canthecur, destructionof lesionwith
liquidnitrogen, palliative off-loading, biopsy, surgical planning,counselingandacomprehensive
informedconsentsessionduringwhichthe patientwasaffordedthe opportunitytoaskany questions
and all questionswere answeredtothe bestof my ability].[The patientwasadvisedof the potential
risksand complicationsassociatedwithexcisionof the lesion.She wasadvisedthataninfectionmay
occur, the lesionmayrecur,a painful scarmightdevelop,numbnessandswellingmayoccurand persist,
that if the lesionisfoundtobe malignanta referral toan oncologistand/orotherspecialistsmaybe
needed,thatadditional surgical andnon-surgical treatmentsmaybe required, annoguaranteeswere
givenasto outcome.]
3) Comprehensive oral andwritteninstructionswereprovidedtothe patientforaftercare.She was
instructedtoremain[non-weightbearing,partial weightbearing, fullyweightbearing] onthe affected
limb.She wasalsoadvisedto[keepthe areadry, keepthe footelevated, totake a few daysoff work, to
use OTC Tylenol, Ibuprofen, orAleve forpaincontrol].Patientwasreappointedfor[5days,1 week, 2
weeks, 3weeks,1month,PRN] for follow-up.The patientwasadvisedtocontactthe office immediately
if problemsarise.
_____________________________
Dr. [User. Name]

11. 10
Figure 1 - Benign Neoplasm on Left
Dermatitis - Established Patient - Biopsy - AFC
Patient:[Patient.Name]AccountNo:[Patient.AcctNo] Date:[Date]
Subjective: Thisisa [Patient.Age] year-oldpatientwhere [Patient.heshe]presentstodaytothe office
witha [new, existing, flareup, reoccurring, postopcomplication] skincomplaintof [hives, pimples,
itchiness, inflammation, irritation] ontheir[left, right, bilateral] lowerextremity.Ithasnotrespondedto
[topical OTCanti-fungals, dryingagents, footsoaks, and otherconservativetreatmentoptions]. Patient
[has, has not] had a similarconditionpreviouslyanddeniesanyrecenttraumaorinciting
events. Patient[denies, relates] afamilyhistoryof thiscondition.
Allergies: [Allergies]
Medications:[Meds]
Past Medical History:[PMH]
Past Surgical History:[PSH]
Past FamilyandSocial History:[PFSH]

12. 11
Reviewof Systems:
GI: [GI]
Musculoskeletal: [MSK]
Integumentary: [Integumentary]
Hematologic/Lymphatic: [Lymphatic]
Allergic/Immunologic:[Immunologic
Objective: The patientisappropriatelydressed,articulate,awake,alert,andorientedx 3, appears
statedage and looksto be in [good*,poor] health.
Vascular:Dorsalispedispulsesare [0,1,2*,3,4]/4 left,dorsalispedispulsesare [0,1,2*,3,4]/4right,and
posteriortibial pulsesare [0,1,2*,3,4]/4left,posteriortibial pulsesare [0,1,2*,3,4]/4 right.Capillary
fillingtime withthe legelevatedis[<5right*, 5 right,>5 right,<5 left*,5 left,>5left] secondsatthe level
of the digital tufts.There [is, are no] ischemicskinchangesevidentin[left, right, bilateral*] lower
extremities.There [is, isnot*] [edema*,pittingedema+??,non-pittingedema+??] noted lower
extremity[left,right, bilateral*].Digital hair[present*, notpresent]
Neurological:Epicriticsensationincludingsharp-dull,lighttouch,proprioception,2-pointdiscrimination
(< 12 mm at level of hallux tuft),vibration(128MHz tuningfork) andprotective threshold(10.0gram
monofilament) are [intact*, diminished] and[with,without*] focal motororsensorydeficit[left, right,
bilateral*] lowerextremities. Normal muscle massappreciatedtoboththe lowerextremityandfoot
[left, right, bilateral*].[Negative*,Positive] Mulder`ssigntothe interspacesof bothfeet.
Dermatological:There isquestionableskinabnormalitynotedon[plantar, dorsal, medial, lateral] [foot,
ankle].There [is, isnot] small vesicleformationthroughout.Otherwise,there isnoevidence of edema,
ecchymosis,orsignsof bacterial infectionof bilaterallowerextremities. Novaricosities,telangectasias,
pigmentedlesionsorsignsof venousstasischangestobilateral lowerextremities. Adequate fatpadding
to the inferioraspectof eachfootappreciated.
Musculoskeletal:One notesa[rectus*, planus, cavus] foottype with[mild, no] gastroc-soleusequinus
deformity.One notes[no*, mild] evidence of limblengthdiscrepancy.Range of motionof the ankle,
subtalarand midtarsal joints[are, are not] painfree andwithinnormal limits.There are [no*,
some] [flexible semi-rigid, rigid] digital contracturesnoted[1L, 1R,2L, 2R, 3L, 3R, 4L, 4R, 5L, 5R]. Muscle
strengthis[1, 2, 3, 4, 5]/5 forall four lowerextremitymusclegroups.
Assessment:[692.9]
Plan:[99202] [11100]
All questionswereansweredindetailandtheyare to returnto office in[one, two] weeks.

13. 12
Figure 2 – Dermatitis
Dermatological Exam Normal
Dermatological Exam: There isnoevidence of edema,erythema,ecchymosis,openlesions,interdigital
maceration,orsignsof bacterial orfungal infectionbilateral lowerextremities. Novaricosities,
telangectasias,pigmentedlesionsorsignsof venousstasischanges bilateral lowerextremities.
Foreign Body Health & Physical
Chief Complaint:This[patient.Age] yearold[patient.Gender]presentstodaystatingthat[patient.heshe]
thinkssomethingisin[patient.hisher] [right, left] foot.Conditionhasbeenpresentfor[1, 2, 3, 4, 5, 6, 7,
8, 9, a few, several] [day, days, week, weeks, month, months, year, years]. Patient[recallssteppingon
glass, thinksit’sa woodsplinter, doesnotrecall anytraumato the areaor steppingonanything. Patient
relates[pain, tenderness, redness,drainage].Athome,patient[hasbeensoakingarea, didtrytoremove
foreignbody, hasnotperformedanyhome care].
Allergies:[Allergies]
Meds: [Meds]
PMH: [PMH]
PSH: [PSH]
FamilyHistory:[FamilyHistory]

14. 13
Social History:[Social History]
Immunizations:[Immunizations]
Reviewof System:
Constitutional:[Constitutional]
CV:[CV]
Endocrine:[Endocrine]
ENMT: [ENMT]
Eyes:[Eyes]
GI: [GI]
GU: [GU]
Immunologic:[Immunologic]
Integumentary:[Integumentary]
Lymphatic:[Lymphatic]
MSK: [MSK]
Neurological:[Neurological]
Psychiatric:[Psychiatric]
Respiratory:[Respiratory]
Physical Exam:
[Vitals]
Constitutionalexam: Patientisapleasant,[patient.Age] yearold[patient.Gender],[innoapparent
distress*, looksgivenage*, well developed*, goodattentiontohygiene*, alert, breathingcomfortably,
cachectic, chronicallyill,comfortable,cooperative,distressed,frail,innoapparentdistress,
malnourished,moderatelyoverweight,moderatelyuncomfortable,morbidlyobese,non-toxic,oriented,
overweight,petite,pleasant,pregnant,sleepy,somewhattired,thin,uncomfortable,undernourished,
witha pleasantexpression withanasarca].
Orientedto[person*, place*, time*, personbutnotplace ortime, place butnot personortime, time
but notpersonor place].
Mood and affectappear[normal andappropriate tosituation*, agitated,angered,anxious,appropriate
for age,appropriate tothe situation,argumentative,calm, confrontational,cooperative,depressed,
fidgety,flat,frustrated,fussy,happy,labile,manic,manipulative,normal,overlyhappy,pleasant,quiet,
sad,stressed,tearful,tense,tired, uncomfortable].

15. 14
Cardiovascular:
Skintemperature is[OPTION=warmtocool proximal todistal*,cool tocool proximal todistal, warmto
warm proximal todistal] onthe rightfootand [warmto cool proximal todistal*, cool to cool proximal
to distal, warmto warmproximal todistal] onthe leftfoot.
Dorsalispedispulsesare [OPTION=0/4, 1/4, 2/4, 3/4, 4/4, non-palpable, palpable, diminished, absent,
bounding] leftand[0/4,1/4, 2/4, 3/4, 4/4, non-palpable, palpable, diminished, absent, bounding] right.
Posteriortibial pulsesare [OPTION=0/4,1/4, 2/4, 3/4, 4/4, non-palpable, palpable, diminished, absent,
bounding] leftand[0/4,1/4, 2/4, 3/4, 4/4, non-palpable, palpable, diminished, absent, bounding] right.
Capillaryfill timeis[OPTION=<3seconds, 3-5 seconds, >5 seconds, delayed, immediate*] leftand
[OPTION=<3 seconds, 3-5seconds, >5 seconds, delayed, immediate*] right.
[No*, pitting, +1, +2, +3, +4] edemaispresent[OPTION=rightlowerextremity, leftlowerextremities,
bilateral lowerextremities*].
Varicosities[OPTION=are, are not*] notedto[OPTION=rightlowerextremity, leftlowerextremities,
bilateral lowerextremities*].
Skin:
Skincoloris notedtobe [normal*, withinnormal limits, cyanotic, reddened, dark].
Skintexture isnotedtobe [normal*, healthyappearing, WNL, thin, dry, atrophic]
Examinationof [hotspots]reveals[painful, erythematous, hyperkeratotic] areawithevidence of [adark
object, glass] presentwithinthe [superficialskin, dermis, epidermis]. The area[doesnotappearto be
infected, appearstobe infectedwithassociatedpurulentdrainage, appearstobe infected with
associatedcellulitis].
Neurological:
Vibratorysensationis[absent, diminished, present*] forleftfootand[absent, diminished, present*] for
rightfoot.
Sharp-dull sensationis[absent, diminished, present*, excessive] forleftfootand[absent,diminished,
present*, excessive] forrightfoot.
Lighttouch sensationis[absent, diminished, present*] forleftfootand[absent, diminished, present*]
for rightfoot.
Deeptendonreflexesare [OPTION=absent, diminished, normal*].
Coordinationis[OPTION=good*, fair, poor]
Musculoskeletal:
Muscle strengthof extremitiesis[normal*,diminishedleft,diminished right].

16. 15
Manual muscle testingis[OPTION=1, 2, 3, 4, 5] outof 5 forall groups.
Impression:
Plan:
PatientwasinstructedonlukewarmwatersoakswithEpsomsaltsbidx 3 days and applydressing
changesdaily.
X-raystakenand reviewed
I&D of foreignbody
Figure 3 - Screw Foot and Flip-Flop Sandal
Hyperkeratosis- Initial
Patient:[Patient.Name]AccountNo:[Patient.AcctNo] Date:[Date]
Chief Complaint:This[Patient.Age]yearold[Patient.Gender] presentstodaywithacomplaintof a [new
onset, chronic, tender, painful] callousformationbeneaththe [first, second, third, fourth, fifth] [right,

17. 16
left] metatarsal headwithpainupon[standing, walking, exercise, performingworkduties, barefoot
walking, closed-toeshoe gear, andevenwhenoff weight-bearing].The conditionhasbeenpresentfor
[days, weeks, months, years] andrecentlyis[worsened, the same, improved].She hasattempted[self-
debridement,soaks, lotions, OTCpadding, shoe gearchanges] which[have, have not] provided
relief. Patient[has, hasnot] hada similarconditionpreviously.She [admits, denies] anyrecenttrauma
or incitingevents. She [has, hasnot] notedanydrainage orbleedingfromthe area.She [admits, denies]
a historyor poor circulationorlossof protective sensationinthe feet.
Allergies: [Allergies]
Medications:[Meds]
Past Medical History:[PMH]
Past Surgical History:[PSH]
Past FamilyandSocial History:[PFH] [Social History]
Reviewof Systems:
Constitutional:[Constitutional]
ENMT: [ENMT]
Cardiovascular:[CV]
Respiratory:[Respiratory]
GI: [GI]
GU: [GU]
Immunologic:[Immunologic]
Endocrine: [Endocrine]
Hematologic/Lymphatic:[Hematologic/Lymphatic]
Integumentary: [Integumentary]
Musculoskeletal: [MSK]
Neurological: [Neurological]
Psychiatric: [Psychiatric]
Examination: The patientisappropriatelydressed,articulate,awake,alert,andorientedx 3,appears
theirstatedage and appearsto be in goodhealth.Theirvitalsare asfollows:[Vitals].

18. 17
Vascular:Dorsalispedispulsesare [0, 1, 2, 3, 4]/4 leftand[0, 1, 2, 3, 4]/4 right.Posteriortibial pulsesare
[0, 1, 2, 3, 4]/4 leftand[0, 1, 2, 3, 4]/4 right.Capillaryrefilltime withthe legelevatedis[<3, 3, >3]
secondsat the level of the digital tuftsbilaterally.There are noischemicskinchangesevidentineither
lowerextremity.Edema[is, isnot] notedinthe [right, left, either, both] [foot, feet, ankle, leg].
Musculoskeletal:There ispainonpalpationof the plantaraspectof the [first, second, third, fourth, fifth]
[right, left] metatarsal where ahyperkeratoticlesionis evident. The associatedtoe [is, isnot]
contractedat the [MTPJ, PIPJ, DIPJ].The contracture is[mild, moderate, severe] andis[rigid, semi-rigid,
reducible] atthe [PIPJ, DIPJ] with[mild, moderate, severe]dorsiflexioncontracture evidentatthe MTPJ
whichis[reducible,semi-rigid,rigid]. EHL tendoncontracture [is, isnot] significant.The associateddigit
isstable to modifiedLachmantestandthere [is, isno] painon palpationof the plantarplate. There are
no othersignificantfootorankle deformitiesappreciatedbilaterally.
Neurological:DeeptendonreflexesincludingAchillesandPatellarare normal,brisk,andsymmetrical
bilaterally.Epicriticsensationincludingsharp-dull,lighttouch,proprioception,2-pointdiscrimination(<
12 mm at level of hallux tuft),vibration(128MHz tuningfork) andprotective threshold(10.0 gram
monofilament) are intact. Nofocal motoror sensorydeficitsnotedineitherlowerextremity.There are
down-goingtoesandanegative clonusbilaterally.Normalmuscle massisappreciatedinbothlower
extremitiesincludingthe feet.Negative Mulder`ssigntothe interspacesof bothfeet. Painperceptionis
normal on palpationof the hyperkeratoticlesionandassociatedtoe.
Dermatological:There isadeepseatedhyperkeratoticlesionunderlyingthe [right, left][1st
,2nd
, 3rd
,4th
,5th
] metatarsal headwhich,afterdebridement,[does, doesnot] reveal anyverruca-typetissue,
characteristics of malignancy,evidence of foreignbodiesorgranulomas,orcardinal signsof infection.
Comprehensivereviewandinspectionof the integumentof bothlower extremities [reveals, revealsno]
evidence of edema,erythema,ecchymosis,openlesions,interdigital macerationorsignsof bacterial or
fungal infection.Novaricosities,telangectasias,pigmentedlesionsorsignsof venousstasischanges
notedineitherlowerextremity. [Adequate, Inadequate] fatpaddingtothe inferioraspectof eachfoot
appreciated.
Impression:Symptomaticlessermetatarsaldeformity[leftfoot, rightfoot, bothfeet] producinga
chronicpainful benignhyperkeratoticlesionanddifficultyambulating.Noevidence of ulceration,
infection,foreignbody,orsuspiciousskinchangeswerenoted.
Treatment:Ihave discussedthe treatmentoptionswiththe patientandhave [debridedthe lesionfull
thickness, dispensedsome silicone paddingwhichpatientwillreapplyona dailybasis, recommended
use of Vaseline orsimilarproducttodecrease friction, stretchedshoes, instructedpatienttopurchase
widerandextra-depthshoeswithalowheel andstiff sole aswell].[Idispensedsoftaccommodative
insolestocushionandcradle the deformity].Discussedandrecommendedmore permanentcustom
orthoticdevicesshouldthe accommodative measuresappliedtodayprovideadequaterelief of
symptoms.If these conservative measuresfailtorelieve symptoms,Ibrieflyadvisedthe patientof the
surgical optionsavailabletocorrectthe underlyingmetatarsal deformity.Iwill discussthose optionsin
greaterdetail withthe patientinthe future if non-surgical treatmentsfail toprovidelong-term
satisfactoryreliefof symptoms.
RTC on a PRN basisforfollowupcare if the painpersistsorworsens.RTCASAPif problemssuchas
increasingpain,redness,swelling,ordrainage are noted,orotherproblemsarise.

19. 18
Hyperkeratosis - Follow-up
Patient:[Patient.Name]AccountNo:[Patient.AcctNo] Date:[Date]
Subjective:Patientpresentstodayforfollow-upof arecurrentandchronic callousformationunderlying
a lessermetatarsal deformitywithpainassociatedwithclosed-toedshoe gear. Patientdidwell withthe
debridementandpaddingbuthave noticedasignificantrecurrence of the callousformationand
discomfortevenwiththe changesinshoe gearandpadding.
PMH, PSH, Medications:Unchangedsince lastvisit.
Objective:The patient'sneurovascularstatusof bilateral lowerextremityisunchangedsince lastvisit.
Musculoskeletal:There ispainonpalpationof the plantar[first, second, third, fourth, fifth] [right, left]
metatarsal headwhere ahyperkeratoticlesionisevident. The metatarsal continuestobe elongatedand
plantardisplacedcompared tothe adjacentmetatarsals.There are noothersignificantfootorankle
deformitiesappreciatedbilaterally.
Dermatological:There isadeepseatedhyperkeratoticlesionplantartothe [first, second, third, fourth,
fifth] [right, left]metatarsal headof the [right, left, bilateral] footwhichafterdebridementdoesnot
reveal anyverruca-type tissue,retainedforeignbodies,orcardinal signsof infection. Otherwise,there is
no evidence of edema,erythema,ecchymosis,openlesions,interdigital macerationorsignsof bacterial
or fungal infectionof bilateral lowerextremities. Novaricosities,telangectasias,pigmentedlesionsor
signsof venousstasischangesbilateral lowerextremities. Adequatefatpaddingtothe inferioraspectof
each footappreciated.
Assessment: Symptomaticlessermetatarsal deformity[right, left, bilateral] foot.
Plan:I have discussedthe previousthe treatmentoptionswiththe patientandhave debridedthe lesion
full thickness.Recommendedcontinueduse of the paddingandinsolesdispensedatpreviousvisit,
recommendeduse of Vaseline orsimilarproducttodecrease friction,andhave againstretchedtheir
shoes.Since patienthasnotrealizedsignificantlong-termbenefitfromtheseconservativemeasuresI
recommendedametatarsal osteotomytocorrectthe condition. Theyhave beenadvisedof the
approximate disabilityinvolvedforthese procedures. Inaddition,the patienthasbeenadvisedastothe
alternativesof care,includingcontinuedconservative care aswell assurgical procedures. The patient
understandsthatif surgical proceduresare performed,there are risksandcomplicationsthatcould
occur, includingbutnotlimitedto:hematomaformation,seromaformation,developmentof aDVT or
phlebitis,infection,painful scartissue formation,limitedmotion,delayedunion,nonunion,malunion,
reactionto implantedbiomaterials,over-correction,undercorrectionwithrecurrence of the
deformities,continuedpain,andthe possibilitythatfuture surgerymayneedtobe performed. The
patientwasgiventhe opportunitytoaskquestionswhichwere answeredtothe bestof myability. The
patientvoicednoconcernsandwill considerall these optionsandschedule accordingly.

20. 19
Hyperkeratosis Debridement
Hyperkeratotic[lesionwas*,lesionswere]debridedthisdate.Patientnotedreducedpainandimproved
ambulationfollowingthe procedure.
Incision & Drainage – Established Patient
Patient:[Patient.Name]AccountNo:[Patient.AcctNo] Date:[Date]
Chief Complaint:This[Patient.Age]yearold[Patient.Gender] presentstodaywithacomplaintof an
ingrown[right,left] [hallux, 1sttoe, 2ndtoe, 3rd toe, 4th toe, 5th toe, foot, ankle, leg].Statesthe
problemis[acute, chronic].The patientadmitsto[odor, redness, swelling, drainage, painassociated
withclosed-toe shoegear, nail comingloose].Previoustreatments:[self-debridement, soaks, local
woundcare,surgical procedures,evaluationbyanotherphysicianandreferral toPodiatry]. Patient
statesthisproblem aReviewof Systems e from[anunknowncause, pedicure, trauma, impropercutting
of nails].
Allergies: [Allergies]
Medications:[Meds]
Reviewof Systems:
Constitutionalsymptoms:[Constitutional]
Musculoskeletal: [MSK]
Integumentary: [Integumentary]
Endocrine: [Endocrine]
Vitals:[Vitals]
Examination:The patientisappropriatelydressed,articulate,awake,alert,andorientedx 3,appears
statedage and looksto be in goodhealth.
Dermatological:The [right, left] [1stdigit, 2nddigit, 3rddigit, 4th digit, 5thdigit, foot, ankle, leg] [medial
border, lateral border, entire nail plate] is[erythematous, edematous, hot, withpurulentdrainage, with
serosanginousdrainage, withnodrainage, incurvatedatthe nail fold, hypertrophiedatthe nail
labia]. Otherwise,noopenlesionsorsignsof bacterial orfungal infectiontothe remainderof either
foot.
Vascular:Dorsalispedisandposteriortibialpulsesare [0, 1, 2, 3, 4]/4 bilateral.Capillaryfillingtime with
the legelevatedis[<5, 5,>5] secondsat the level of the digital tuftsbilaterally.There [are, are not]
ischemicskinchangesevident.

21. 20
Impression:[abscess,ingrowntoenail, sub-ungalulcer, cellulitis]
Treatment:Ihave discussedthe treatmentoptionswiththe patientanddue tothe infectednature of
the area I recommendedanincisionanddrainage withremoval of all infectedtissue.Idiscussedthe
risks,complications,andexpectedrecoverycourse withthe patientandtheyunderstandthe nail margin
will regrowandmaybecome symptomaticagaininthe future. Afterobtainingappropriateinformed
consentandverifyingthe correctdigit,the toe was[anesthetizedwith3ccof a half and half solutionof
0.5% Marcaine™ plainand 1% lidocaine plainafter whichthe digitwas] preppedanddrapedinthe usual
asepticmanner.Verificationof anesthesiawasperformed.[A tourniquetwasappliedtothe toe for10
minutes].The [areawasincisedanddrained, offendingnail borderwasremovedandirrigatedwith
hydrogenperoxide].Pus[was, wasnot] expressed.Bacitracinanda dry sterile dressingwasapplied.
[The tourniquetwasremoved].Explicitoral andwrittenpostoperative instructionswere dispensed.We
will see the patientinfollow-upin[11days, 1 week, 2weeks, prn].
Incision & Drainage –New Patient
Patient:[Patient.Name]AccountNo:[Patient.AcctNo] Date:[Date]
Chief Complaint:This[Patient.Age]yearold[Patient.Gender] presentstodaywithacomplaintof [an
ingrownnail, aninfectedtoenail, apainful nail, anabscess,aredarea] of the [right, left, bilateral]
[hallux, 2ndtoe, 3rd toe, 4th toe, 5th toe, foot, leg].Statesthe problemis[acute, chronic, beenpresent
for a while butthoughtitwouldresolve onitsown].The patientadmitsto[odor, redness, clear
drainage, pusdraining, painassociatedwithclosed-toeshoe gear, burning, heat, pain].Previous
treatments:[antibioticsprescribedbyanotherphysician, self-debridement, soaks, local woundcare,
surgical procedures, nothingasitistoo painful totouch, benignneglect].Patientstatesthisproblem
arose from [anunknowncause, pedicure, trauma, impropercuttingof nails, improperlyfittedshoes,
trauma, swellingof the legsandfeet].
Allergies: [Allergies]
Medications:[Meds]
Past Medical History:[PMH]
Past Surgical History:[PSH]
Past FamilyandSocial History:[PFH];[Social History]
Reviewof Systems:
Constitutional:[Constitutional]
ENMT: [ENMT]

22. 21
Cardiovascular:[CV]
Respiratory:[Respiratory]
GI: [GI]
GU: [GU]
Immunologic:[Immunologic]
Endocrine: [Endocrine]
Hematologic/Lymphatic:[Hematologic/Lymphatic]
Integumentary: [Integumentary]
Musculoskeletal: [MSK]
Neurological: [Neurological]
Psychiatric: [Psychiatric]
Examination:The patientisappropriatelydressed,articulate,awake,alert,andorientedx 3,appears
theirstatedage and appearsto be in goodhealth.Theirvitalsare asfollows:[Vitals].
Dermatological:The [right, left] [1stdigit,2nddigit, 3rddigit, 4th digit, 5thdigit, foot, ankle, leg] [medial
border, lateral border, entire nail plate] is[erythematous, edematous, withpurulentdrainage, with
serosanginousdrainage, withnodrainage, incurvatedatthe nail fold, hypertrophiedatthe labial nail,
withgranulomatous lesion, loose fromthe nail bedpartially, loose fromthe nail bedcompletely].[No
openlesionsorsignsof bacterial orfungal infectiontothe remainderof eitherfoot].
Neurological:Protective sensation[intact, diminished, absent].Pain[is, isnot] appreciatedtothe area.
Vascular:Dorsalispedisandposteriortibialpulsesare [0, 1, 2, 3, 4]/4 bilateral.Capillaryfillingtime with
the legelevatedis[<5, 5, >5] secondsatthe level of the digital tuftsbilaterally.There [are, are not]
ischemicskinchangesevident.
Musculoskeletal: [Muscle strengthforall prime moversof the footare intact bilateral withappropriate
muscle tone andsymmetryandfull range of motionforall jointswithoutcrepitationorinstability
appreciated, muscle weaknessappreciatedasaresultformedical status, limitationof motionand
stiffnessappreciatedasa resultof currentmedical condition].
Impression:[paronychia, severe abscess, symptomaticingrowntoenail, sub-ungalulcer, granuloma,
hematoma, seroma,ulceration, subungual ulcer, cellulitis] [1R, 2R, 3R, 4R, 5R, 1L, 2L, 3L, 4L, 5L, right
foot, rightleg, leftfoot, leftleg][medial border, lateral border, entire nailplate]
Plan:I have discussedthe treatmentoptionswiththe patientanddue to the nature of the infection,I
recommendeda[slantbackprocedure, incisionanddrainage withremovalof all infectedtissueandthe
nail margin, permanentremoval of the nail margintopreventfuture complications, removal of loose
nail plate, chemical cauterizationof the granuloma, incisionanddrainage of wound, monitoringthe for

23. 22
improvement].Idiscussedthe risks,complications,andexpectedrecoverycourse withthe patientand
theyunderstandthe areamay become symptomaticagaininthe future.
Treatment:Appropriate informedconsentwasobtainedandverificationof the correctdigitwasdone.
[The toe was anesthetizedwith3ccof a half andhalf solutionof 0.5% Marcaine™ plainand1% lidocaine
plain, Noanesthesiawasrequiredasthe patientwas insensateenoughtotolerate the procedure, the
digitwaspreppedinthe usual asepticmanner].A tourniquetwas[appliedtothe digit,applied tothe
ankle,notapplied].[The offendingnail borderwasremovedalongwithall granulomatousand
devitalized tissue andthenthe woundwasirrigatedwithhydrogenperoxide anddressedwithbacitracin
and a dry sterile dressing, 3applicationsof phenol(89% CarbolicAcid) at30 secondseachwere applied
viamicro tipcotton applicatorthenthe areawas irrigated withisopropyl alcohol.The digitwassprayed
withhydrogenperoxide solutionwhichdiscolorsthe phenolinaneffortidentifyandremove inadvertent
contact of the phenol withnormal skin.Amerigel®wasappliedtothe woundtoneutralize the phenol,
the nail plate wasfreedfromthe nail bedand the woundwasdressedwithbacitracinanda non-
adherentdressing,the granulomatouslesionwasdebridedwithsilvernitrate,the granulomatouslesion
was debridedbywayof sharpexcision,the areawasincisedand drainedof all pusandfluid
accumulationscreatingahealthywoundbase andirrigatedwithNSS].A lightlycompressivedressing
was appliedwithaprotective outerdressing. [The tourniquetwasremoved].Explicitoral andwritten
postoperative instructionswere dispensed.We willsee the patientinfollow-upin[1week, 11 days, 2
weeks,prn]. Shouldproblemsarise patientagreestocome to the office forevaluation.
Ingrown Nail – Follow-up
Patient:[Patient.Name]AccountNo:[Patient.AcctNo] Date:[Date]
Subjective:Patientreturns2weekssince undergoinganail marginprocedure on[right, left, bilateral]
[1st, 2nd,3rd, 4th, 5th] digit. Patienthasbeendoingverywell sincelastvisitandhasbeenvery
compliantwithpostoperativeinstructions,soakingBiDwithQ-tipcleansingof the offendingnail margin,
use of topical antibiotics,bandage coverage,anduse of open-toe shoe gearasmuchas possible.The
patientdeniesanyfever,chills,nauseaorvomiting,calf painortenderness,shortnessof breath,chest
pain,and local or systemicsignsof infection.
Objective: Nochange fromthe previousmusculoskeletalexaminationof bilateral lowerextremity.The
offendingnail marginis[cleananddryand intactwithno evidence of earlyrecurrence, draining
serosanginousfluid,drainingpurulentfluid,erythematous].Thereisnopainon palpationof the
offendingnail margin.
Assessment:statuspostnail procedure [1,2, 3, 4, 5] [right,left] [doingwell, unchanged, worsening].
Plan:I cleansedthe toenail marginforthe patientandrecommended[dischargefromcare as woundis
healed, continueduse of topical antibioticsandbandage application,use of anopen-toe shoe whenever
possible,dailysoaksuntil astable escharhasformed].Iwill see patientbackona [PRN basis, in1 week,
in2 weeks] andhave cautionedpatientregardingnail regrowthand/orrecurrence.

24. 23
Figure 4 - Healing Progression of Postoperative Ingrown Toenail
Kissing corn
Patient:[Patient.Name]AccountNo:[Patient.AcctNo] Date:[Date]
Subjective:Patientpresentstodayforfollow-upof arecurrentandchronic callousformationbetween
the toesin the [1st,2nd, 3rd, 4th] innerspace of the [right,left] foot.Thisisassociatedwithpainin
closed-toedshoegear. Patientdidwell withthe debridementandpaddingbuthave noticeda
significantrecurrence of the callousformationanddiscomfortevenwiththe changesinshoe gearand
padding.
PMH, PSH, Medications:Unchangedsince lastvisit.
Objective:The patient'sneurovascularstatusof bilateral lowerextremityisunchangedsincelastvisit.
Musculoskeletal:There [is, isnot] painonpalpationof the [1st,2nd, 3rd, 4th] webspace of the [right,
left] footwhere ahyperkeratoticlesionisevident. There are noothersignificantfootorankle
deformitiesappreciatedbilaterally.

25. 24
Dermatological:There isadeepseatedhyperkeratoticlesioninthe webspacewhichafterdebridement
doesnotreveal anyverruca-type tissue,retainedforeignbodies,orcardinal signsof infection.
Otherwise,thereisnoevidence of edema,erythema,ecchymosis,openlesions,interdigital maceration
or signsof bacterial or fungal infectionof bilateral lowerextremities. Novaricosities,telangectasias,
pigmentedlesionsorsignsof venousstasischangesbilateral lowerextremities. Adequatefatpaddingto
the inferioraspectof eachfootappreciated.
Radiographs:Reveal [nogrossbonyabnormalities,hypertrophiccondyle adjacenttothe lesion,
underlappingdigitadjacenttothe lesion].
Assessment:Symptomatichelomamolle [1st
,2nd
,3rd
, 4th
] innerspace of the [right,left] foot.
Plan:I have discussedthe treatmentoptionswiththe patientandhave debridedthe lesionfull
thickness.Recommendedcontinueduse of the paddingandinsolesdispensedatpreviousvisit,
recommendeduse of Vaseline orsimilarproducttodecrease friction,andhave againstretchedtheir
shoes.Since patienthasnotrealizedsignificantlong-termbenefitfromtheseconservativemeasuresI
recommendedaprocedure tocorrectthe condition. The recommendedprocedure is[percutaneous
osteotripsy, arthroplasty, exostectomy, ostectomy,partial saucerization] of the involvedphalangesof
the [right,left] [1st,2nd,3rd, 4th, 5th] digits.Theyhave beenadvisedof the approximate disability
involvedforthese procedures. Inaddition,the patienthasbeenadvisedas tothe alternativesof care,
includingcontinuedconservative care aswell assurgical procedures. The patientunderstandsthatif
surgical proceduresare performed,thereare risksandcomplicationsthatcouldoccur,includingbutnot
limitedto:hematomaformation,seromaformation,developmentof a DVTor phlebitis,infection,
painful scartissue formation,limitedmotion,delayedunion,nonunion,malunion,reactiontoimplanted
biomaterials,over-correction,undercorrectionwithrecurrence of the deformities,continuedpain,and
the possibilitythatfuture surgerymayneedto be performed. The patientwasgiventhe opportunityto
ask questionswhichwereansweredtothe bestof myability. The patientvoicednoconcernsandwill
considerall these optionsandschedule accordingly.
Figure 5 - Soft Kissing Corn

26. 25
Lesion Description
Lesionissurface isdescribedas[pigmentedblack, pigmentedbrown, pigmentedblue, homogenousin
color, heterogeneous incolor].The surface is[flat, nodular, raised, waxy].The texture is[dry, inflamed,
moist, peeling, scaling, supple, ulcerated].Measures[1,2,3,4,5,6,7,8,9,10] [mm, cm, inches] longby[1 ,
2, 3, 4, 5, 6, 7, 8, 9, 10] [mm, cm, inches] wide.The bordersare describedas[regular, irregular, notwell
defined, welldefined, serpintiginous, rolled, hyperkeratotic].[hotspots].
Nail Avulsion - Initial
Patient:[Patient.Name]AccountNo:[Patient.AcctNo] Date:[Date] Provider:[Provider.Name]
Chief Complaint: Patientisa[Patient.Age]yearold[Patient.Gender] whopresentstodaywithcomplaint
of painful [ingrown, thickened, loosened] nail,on[right, left, bilateral] [1, 2, 3, 4, 5] toe whichhas had
some slightodor,slightredness,cleardrainage,andpainassociatedwithclosed-toeshoe gearandhas
not respondedtoself-debridement,soaks,andlocal woundcare.The problemhasbeenpresentfor
[days, weeks, months].Patientisinterestedintreatmentoptions.
Allergies: [Allergies]
Medications:[Meds]
Past Medical History:[PMH]
Past Surgical History:[PSH]
FamilyHistory:[FamilyHistory]
Social History:[Social History]
Reviewof Systems:
Constitutionalsymptoms:[Constitutional]
Eyes:[Eyes]
Ears, Nose,Mouth,Throat: [ENMT]
Cardiovascular:[CV]
Respiratory: [Respiratory]
GI: [GI]
GU: [GU]

27. 26
Musculoskeletal: [MSK]
Integumentary: [Integumentary]
Neurological: [Neurological]
Psychiatric: [Psychiatric]
Endocrine: [Endocrine]
Hematologic/Lymphatic: [Lymphatic]
Allergic/Immunologic:[Immunologic]
Physical Examination: The patientisappropriatelydressed,articulate,awake,alert,andorientedx 3,
appearsstatedage and looksto be ingood health.
[Vitals]
Dermatological:There iserythemaandedemabutno purulentdrainage,andanassociated[incurvated,
thickened, loosened] nail withhypertrophiedlabialnail foldappreciatedtothe offending[right, left,
bilateral] [medialborder, lateralborder, medial andlateral borders, entire] [1st
,2nd
,3rd
, 4th
, 5th
] nail. No
proximal cellulitisordeepabscessevidentatthistime.Otherwise,noopenlesionsorsignsof bacterial
or fungal infectiontothe remainderof eitherfoot.
Neurological:Painisappreciatedtothe offending[right, left, bilateral] [medial,lateral, bothmedialand
lateral] nail borderof the greattoe.DeeptendonreflexesincludingAchillesandPatellarare normal,
brisk,andsymmetrical bilateral.Epicriticsensationincludingsharp-dull,lighttouch,proprioception,2-
pointdiscrimination(<12 mm at level of hallux tuft),vibration(128 MHz tuningfork) andprotective
threshold(10.0gram monofilament) are intactandwithoutfocal motoror sensorydeficitbilateral lower
extremities.There are downgoingtoesanda negative clonusbilateral.Normalmuscle massappreciated
to boththe lowerextremityandfootbilateral.The patientcanheel andtoe walkwithease aswell as
arise froma seatedpositionunassisted.
Vascular:Dorsalispedisandposteriortibialpulsesare [0, 1, 2*, 3, 4]/4 bilateral.Capillaryfillingtime
withthe legis[<3*, 3, >3] secondsat the level of the digital tuftsbilateral.There are noischemicskin
changesevidentinbilateral lowerextremities.
Musculoskeletal:Properalignmenttothe lowerlegs,stableankle tomanual stress(inversionand
anteriordrawer),hindfoot,mid footandforefootbilateral lowerextremities.Muscle strengthforall
prime moversof the lowerleg,ankle,andfootare gradedat 5/5 bilaterally.Appropriatemuscle tone
and symmetryof bilateral lowerextremities.Full,fluidrange of motionforall jointsfromthe ankle joint
distal withoutcrepitationorinstabilityappreciatedinbilateral lowerextremities.
Impression: [Onychocryptisis, Onychomycosis, Onycholysis] [with, without] paronychia,[1st
,2nd
,3rd
, 4th
,
5th
] toe [right,left, bilateral] [medialborder, lateral border, bilateral borders, entire nail].
Treatment:Treatmentoptionswere discussed. Atthistime Irecommendednail avulsiontothe affected
digits. Afterappropriate consentandverifyingthe correct[digit, digits],the toe wasanesthetizedwith3

28. 27
cc of 1:1 mixture of 0.5% Marcaine plainand1% lidocaine plain. A tourniquetwasappliedtothe toe(s).
The offendingnail border(s) wasavulsed. The tourniquetwasremovedafterverifyingthatall pathologic
nail tissue wasremoved,andanantibiotic-impregnatedcompressiondressingappliedtothe toe itself.
Explicitoral andwrittenpostoperative instructionswere dispensed. We will seethe patientinfollow up
intwo weeks’time orsoonershouldproblemsarise.
[Provider.Name]
cc: [Referral.Name]
Nail Avulsion - Follow-up
Patient:[Patient.Name]AccountNo:[Patient.AcctNo] Date:[Date] Provider:[Provider.Name]
Subjective:Patientreturns2weeks since undergoinganail avulsionon[right, left, bilateral][1st
,2nd
, 3rd
,
4th
, 5th
] digit. Patienthasbeendoingverywell since lastvisitandhasbeenverycompliantwith
postoperative instructions,includingsoaksanddressingchanges.The patient statesthe digitis[not
improved, mildlyimproved, greatlyimproved*]. Ptrelates[no, mild*, moderate] drainage. The patient
[has, has not] beentakingoral antibiotics.
Objective:The patientis[intact, diminished] fromaneurovascularstandpoint.No change fromthe
previousmusculoskeletal examinationof bilaterallowerextremity.The offendingnail marginishealing
well with[wet*, dry] escarand[no, mild*,moderate] marginalerythemapresent.There is[no, mild*,
moderate] painonpalpation of the offendingnail margin. [No, Mild*,Moderate] serousdrainage
present.
Assessment:2weeksstatuspostnail avulsion,[improving*,worsening, unchanged, resolved].
Plan:I cleansedthe toenail marginforthe patientandrecommendedcontinueduse of topical
antibiotics,dailydressingchanges,andsoaksuntil the drainage hasstopped,anduntil astable eschar
has formed,atwhichpointthe above home care may be discontinued.The patientwillfollow up[2
weeks, 4weeks, 10 weeks,PRN*].Ihave cautionedpatientregardingnail regrowthand/or
recurrence. Shouldthe physical therapist notice anyincreasedpain,swelling,rednessordrainage they
will contactthe office immediately.
Onychomycosis - Established Patient
Patient:[Patient.Name]AccountNo:[Patient.AcctNo] Date:[Date]

29. 28
Subjective:Patientisa[Patient.Age] yearold[Patient.Gender] whopresentstoday[ambulating, ina
wheelchair, usingawalker, usingacane] forevaluationandtreatmentof [onychomycosis, painful
mycoticnails, diabeticcondition, podiatriccondition].The patienthasbeen[usingtopical ClarusAFoil
on the nails, usingNAFTIN creamonthe nail bed(s) afternail removal, unabletoperformself-nail care
due to the severe nature of nail deformitieswhichcause limitationinambulationdue topainand
pressure inshoe gear, havingnailsprofessionallydone due tothe diabeticriskfactorsassociatedwith
attemptedcare].Patientwaslastseenby Dr.[Dupuis, Holman, D.Freitas, P.Freitas, Flurry, Binkard, Willis,
Dunn, Rush, May, W. Willis, S.Willis, Osban, Tillery, Bumaget, Sarkoche, Snow, Garg, Pinkston, Mian,
Navas, Martin, Hoang, Messick, Kincaid, Kinselman, Johnson] on[1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12],
[2009, 2010, 2011, 2012, 2013, 2014, 2015].
Objective: [Hotspots] are [improvingproximallybutstilldiscoloreddistally,resolvedinsignsof
infection, elongated, thick, hypertrophic, crumbly, discolored, deformed, ridged, malodorous, lysing
withfriable subungualdebriswhichafterdebridementtounderlyingnail bedrevealsacharacteristic
fungal/yeast/moldodorandconsistency].There [is, isno] surroundingcellulitis.There [is, isno] deep
incurvation.There [is, isnot] evidenceof bacterial infection.[Review of the integumentrevealedno
woundswithinfectionnorulcerations, the webspacesare macerated.] The neurovascularstatusis
unchangedascomparedto previousexaminations.Noischemiaorcyanosisnoted.
Assessment:Symptomaticonychomycosiswith[improvementusingtopical treatments, improvedusing
oral treatment, markedlimitationof ambulation, pain, ahighlikelihoodof complicationsif nottreated
professionallyonaregularbasis].
Plan:[Mechanical andelectrical debridementof the mycotictoenailswasperformedandthe toenails
were reduced toas normal a thicknessandlengththatpatienttolerance wouldallow].Thiswasdone on
[1-5, 6-10] nails.[Thisimprovedthe texture, Thisgreatlyreducedthe painwithpressureappliedtothe
nail plates].[The patient'sabilitytoambulate wasalsoobservedtobe improvedfollowing
debridement].[Antifungal andantisepticsolutionwasappliedtothe nails].Advisedto[use AFnail oil,
use tea tree oil, use Lamisil, continue touse lasertreatments, continuetouse nail oil toprevent
recurrence, Onmel] totreatthe fungal infection.The patient[does,doesnot] desiretotreatthe
infection.
Returnto clinic[asneeded, 10weeks, 12 weeks, 6months, one year].

30. 29
Figure 6 - Proximal subungual onychomycosis (arrow)
Onychomycosis - New Patient
Patient:[Patient.Name]AccountNo:[Patient.AcctNo] Date:[Date]
Chief Complaint: This[Patient.Age] yearold[Patient.Gender] presentstodayforevaluationand
treatmentof [painful, discolored, thick, loose, mycotic, elongated] nails.The patient[hasbeenable, has
beenunable, becauseof diabetesmellituswasadvisedbyPCPnot, because of use of bloodthinnerswas
advisedby pcpnot] to provide self-nail care.[Due tothe severe nature of deformitythe nailscause
limitationinambulationdue topainandpressure inshoe gear.] [Patienthasattemptedself-
debridementwithlimitedsuccessorhascausedharm to themselves.] PatientwaslastseenbytheirPCP,
[Patient.PrimaryPhysician] on[Patient.DateLastSeen].
Allergies: [Allergies]
Medications:[Meds]
Past Medical History:[PMH]
Past Surgical History:[PSH]
Past FamilyandSocial History:[PFH];[Social History]

31. 30
Reviewof Systems:
Constitutional:[Constitutional]
ENMT: [ENMT]
Cardiovascular:[CV]
Respiratory:[Respiratory]
GI: [GI]
GU: [GU]
Immunologic:[Immunologic]
Endocrine: [Endocrine]
Hematologic/Lymphatic:[Hematologic/Lymphatic]
Integumentary: [Integumentary]
Musculoskeletal: [MSK]
Neurological: [Neurological]
Psychiatric: [Psychiatric]
Examination:The patientisappropriatelydressed,articulate,awake,alert,andorientedx 3,appears
theirstatedage and appearsto be in goodhealth.Theirvitalsare asfollows:[Vitals].The patient
appears[well,poorly] nourishedand[well,poorly groomed],NAD.
Vascular:Dorsalispedisare gradedat[0/4 b/l, 1/4 b/l, 2/4 b/l, 3/4 b/l, 4/4 b/l, monophasicb/l, biphasic
b/l, triphasicb/l, 0/4 right, 0/4 left, 1/4 right, 1/4 left, 2/4 right, 2/4 left, 3/4 right, 3/4 left, 4/4 right, 4/4
left, monophasicleft, bipasicleft, triphasicleft, monophasicright, biphasicright, triphasicright, ] and
posteriortibial pulsesare gradedat[0/4 b/l, 1/4 b/l, 2/4 b/l, 3/4 b/l, 4/4 b/l, monophasicb/l, biphasic
b/l, triphasicb/l, 0/4 right, 0/4 left, 1/4 right, 1/4 left, 2/4 right, 2/4 left, 3/4 right, 3/4 left, 4/4 right, 4/4
left, monophasicleft, biphasicleft, triphasicleft] Digital hairgrowth[present, sparse, absent] bilateral.
CFT withthe legelevatedwas[lessthan3 seconds, 3 seconds, more than3 seconds] at the distal toes
bilateral.There [is,isnot] evidence of ischemicskinchanges.Temperature fromthe tibiatothe toesis
[warm,cool] at anteriortibiato[warm,cool] at the distal digitsbilateral.
Neurological: [CoordinationWNLtorightand leftlowerextremity, Protectivesensationgrossly intact,
Protective sensationdiminished.]
Dermatological:[Hotspots] is[mildly,severely,elongated, thickened, yellow/discolored, crumbly, ridged,
lysingwithfriable subungualdebris].There is [surroundingcellulitis, deepincurvationof nail(s),
evidence of surroundingbacterial infection, evidence of surroundingfungal infection, evidence of
chronicpickingat the nail and ungal labia, abscess of nail(s),nopathologicskinchanges].Classfindings

32. 31
include [absent(0/4), diminished(1/4), normal (2/4), strong(3/4), bounding(4/4)] pedal pulses
[bilaterally,unilaterally][normal, diminished,absent]digital/pedalhairgrowth,[no, mild, moderate,
severe] telangectasiasand[no, mild, moderate, severe] lowerlegedema.Atriskareasare [present,
absent].Openulcerationsare [absent,present].
Musculoskeletal:Patientis[able towalk,able towalkwithawalker,able towalkwitha cane,ina
wheelchair].[Stable footposture withoutobviousstructural deformitiesnotedbilateral,Forefootand
digital malpositioninfootstructure, Midfootmalpositioninfootstructure, Rearfootstructural
malposition, Anklefootstructure malposition].Muscle strengthof the lowerextremityshows[normal,
weak,absent] primarymovers.[Stiff contractedjointspresent., Fluidrange of motionforall jointsfrom
the ankle to the distal toeswithoutcrepitationnotedbilateral., Range of motionof jointsislimited.]
Assessment:Symptomaticonychomycosis[tineapedis, tineainterdigitus, onychocryptosis, ingrown
toenail]
Plan:The offendingnail platesandmarginswere mechanicallyandelectricallydebrided[1-5,6-10] in as
normal thicknessandlengthasthe patientwouldtolerate.Thisrenderedthe patientasymptomaticwith
appliedpressure tothe nail plate.[Thiswasalsoevidencedbypainfree ambulation].Antifungal and
antisepticsolutionwasappliedtothe nails.Recommendpatientconsideroptionsof treatmentto
include:[Clarus™topical oil, Penlac® topical agent, OTCAFtherapy, prescriptionstrengthAFtherapy,
lasertreatment, oral antifungal therapy] onthe toenailstoattempttotreatthe fungal infection.Atthis
pointthe patientelectstouse [Clarus™ topical oil,Penlac® topical agent, OTCAFtherapy, prescription
strengthAFtherapy, lasertreatment, oral antifungaltherapy]. Instructedtowashsocksinbleachas well
as the bedsheets.AlsoinstructedtosprayshoeswithAF sprayeverynightandletdryovernight.
Returnto clinic[asneeded, 10weeks, 12 weeks, 6months, 12 months].
Phenol and Alcohol Matrixectomy
Treatment: I have discussedthe treatmentoptionswiththe patientanddue tothe painful nature of the
toe and severe incurvatednail edge presentIrecommendpermanentremoval of the [entiretoenail,
medial borderof toenail,lateral borderof toenail].Idiscussedthe risks,complications,andexpected
recoverycourse withthe patientandtheyunderstandthe nail,nail margin,orspiculesof it,mayre-grow
and maybecome symptomaticagaininthe future. Afterappropriate consentandverifyingthe correct
digit,aninjectionwasperformedusing[1,2, 3*, 4, 5]cc of a 1:1 mix of 1% Lidocaine and0.5%
Marcaine™ afterwhichit waspreppedanddrapedinthe usual asepticmanner.Verificationof
anesthesiawasperformedafterwhichatourniquetwasappliedtothe toe.Uponproperanesthesia,the
[entire toenail,medial borderof toenail,lateral borderof toenail, medial andlateral bordersof the
toenail] wasfreedfromitssofttissue attachmentsandexcisedintoto.Areawasinspectedfor spicules
and none were found. 3applicationsof phenol (89% CarbolicAcid) applied,for30 secondseachand the
area irrigated withalcohol. The digitwassprayedwithhydrogenperoxide solutionwhichdiscolorsthe
phenol inaneffortidentifyinadvertentburningof normal skin.Amerigel®wasappliedanda lightly
compressive non-sticksteriledressing.The tourniquetwasremoved.A prompthyperemicresponse was
notedto the toe.Explicitoral andwrittenpostoperative instructionswere dispenseddescribingthe
post-operative care of the site.We will see the patientinfollow upintwoweeks’timeif neededor
soonershouldproblemsarise.

33. 32
Phenol and Alcohol Matrixectomy – Established Patient
Patient:[Patient.Name]AccountNo:[Patient.AcctNo] Date:[Date]
Chief Complaint: Patientisa[Patient.Age]yearold[Patient.Gender] whopresentstodaywithcomplaint
of chronicingrown nail on[right, left, bilateral][great, 2nd
, 3rd
, 4th
, 5th] toe with[odor, erythema,clear
drainage,cloudydrainage,painwithclosedtoedshoes] and[has,hasnot] respondedtoself-
debridement,soaks,andlocal woundcare. Patienthashada similarconditionpreviouslytreated
[conservatively, surgically, withdebridement] anddesirestohave a permanentprocedure sothe nail
edge will notgrowback.
Allergies: [Allergies]
Medications:[Meds]
Reviewof Systems:
Constitutionalsymptoms:[Constitutional]
Musculoskeletal: [MSK]
Integumentary: [Integumentary]
Neurological:[Neurological]
Endocrine:[Endocrine]
Physical Examination: The patientisappropriatelydressed,articulate,awake,alert,andorientedx 3,
appearsstatedage and looksto be ingood health.
Dermatological:There is[erythema, edema, pus, cleardrainage] andanassociatedincurvatednail with
hypertrophiedlabial nailfoldappreciatedtothe offendingnail border.
Vascular:Dorsalis pedisandposteriortibialpulsesare [0, 1, 2, 3, 4]/4 bilateral.Capillaryfillingtime with
the legelevatedis[<5, 5, >5] secondsatthe level of the digital tuftsbilateral.There are noischemicskin
changesevidentinbilateral lowerextremities.
Impression: Chroniconychocryptosis [1, 2,3, 4, 5] [right, left, bilateral] [medial border, lateral border,
medial andlateral borders,entirenail].
Treatment: I have discussedthe treatmentoptionswiththe patientanddue tothe chronic nature
patientelectstohave the above nail(s) removedpermanently.Idiscussedthe risks,complications,and
expectedrecoverycourse withthe patientandtheyunderstandthe nail margin,orspiculesof it,mayre-
grow andmay become symptomaticagaininthe future. Afterappropriateconsentandverifyingthe
correct digit(s),the toe wasanesthetizedwith3cc of 0.5% Marcaine™ plain,afterwhichitwasprepped

34. 33
and drapedinthe usual asepticmanner. Verificationof anesthesiawasperformedafterwhicha
tourniquetwasappliedtothe toe. The offendingnail borderwasremoved,3applicationsof phenol
(89% CarbolicAcid) applied,andthe areairrigatedwithalcohol. The digitwas sprayed withhydrogen
peroxide solutionwhichdiscolorsthe phenolinanefforttoidentifyinadvertentburningof normal skin.
Amerigel®waspackedinthe woundanda lightlycompressive drysterile dressingwasapplied.The
tourniquetwasremoved. Explicitoral andwrittenpostoperative instructionswere dispensed. We will
see the patientinfollowupintwoweek’stime orsoonershouldproblemsarise.
Phenol and Alcohol Matrixectomy – New Patient
Patient:[Patient.Name]AccountNo:[Patient.AcctNo] Date:[Date]
Chief Complaint: Patientisa[Patient.Age]yearold[Patient.Gender] who presentstodaywithcomplaint
of chronicingrownnail on[right, left, bilateral][great, 2nd
, 3rd
, 4th
, 5th
] toe.Admits[pain, redness,
drainage, odor, infection, paininshoe gear] andhasnot respondedtoself-debridement,soaks,andlocal
woundcare. Previoustreatments:[notreatment,local woundcare, debridement, surgical procedures,
soaks].[Patientdesirestohave apermanentprocedure sothe nail edge willnotgrow back].
Allergies: [Allergies]
Medications:[Meds]
Past Medical History:[PMH]
Past Surgical History:[PSH]
Past FamilyandSocial History:[PFH];[Social History]
Reviewof Systems:
Constitutional:[Constitutional]
ENMT: [ENMT]
Cardiovascular:[CV]
Respiratory:[Respiratory]
GI: [GI]
GU: [GU]
Immunologic:[Immunologic]
Endocrine: [Endocrine]

35. 34
Hematologic/Lymphatic:[Hematologic/Lymphatic]
Integumentary: [Integumentary]
Musculoskeletal: [MSK]
Neurological: [Neurological]
Psychiatric: [Psychiatric]
Examination:The patientis[appropriatelydressed, articulate, awake, alert, andorientedx 3] Patient
appearsto be in [good, fair, poor, neglected] health. Vitalsare asfollows:[Vitals].
Dermatological:There is[erythemaandedema,purulentdrainage, incurvatednail withhypertrophied
labial nail fold, nosignsatthistime as the nail isquiescent] appreciatedtothe offending[right, left,
bilateral] [medial, lateral, medial andlateral] [hallux*, 2nd
,3rd
, 4th
, 5th
] nail border(s).[Proximal cellulitis,
distal cellulitis,deepabscess] evident.
Neurological:Pain[is*,isnot] appreciatedtothe offendingnail border(s). Epicriticsensationappears
[intact, absent].The patient[canheel andtoe walkwithease, arise fromaseatedpositionunassisted,
cannot walk].
Vascular:Dorsalispedisandposteriortibial pulsesare [0, 1, 2, 3, 4]/4 bilateral.Capillaryfillingtime with
the legelevatedis[<3, 3, >3] secondsatthe level of the digital tuftsbilateral.There [are,are no]
ischemicskinchangesevidentinbilateral lowerextremities.
Impression: Chroniconychocryptosis[1, 2,3, 4, 5] [right, left, bilateral] [medial, lateral, medialand
lateral] border(s).
Treatment: I have discussedthe treatmentoptionswiththe patientanddue tothe chronic nature of
the toenail andsevere incurvatednail edge presentIrecommendedaremoval of the nail margin(s) and
all infectedtissue.Idiscussedthe risks,complications,andexpectedrecoverycourse withthe patient
and theyunderstandthe nail margin,orspiculesof it,mayre-grow andmay become symptomaticagain
inthe future. Afterappropriate consentandverifyingthe correctdigit,the toe wasanesthetizedwith3
cc of a 50/50 mixture of 0.5% Marcaine™ and 1% lidocaine plainafterwhichitwaspreppedanddraped
inthe usual asepticmanner.Verification of anesthesiawasperformedafterwhichatourniquetwas
appliedtothe toe. The offendingnail border(s)wasremoved,3applicationsof phenol (89% Carbolic
Acid) applied,andthe areairrigatedwithalcohol.The digitwas sprayed withhydrogenperoxide solution
whichdiscolorsthe phenol inaneffortidentifyinadvertentburningof normal skin.Amerigel®was
appliedanda lightlycompressive drysteriledressing.The tourniquetwasremoved. Explicitoral and
writtenpostoperative instructionswere dispensed.The patientwasgivenoptionstoeitheruse
Amerigel®twice dailywithdressingchangesorsoakthe toe in Epsomsalts3 timesdailyfortenminutes
each time afterwhichapplyadry sterile dressing.Patientwasadvisedtotake apainrelieverof their
choice as needed.We will seethe patientinfollow upin11-14 day’stime or soonershouldproblems
arise.

36. 35
Figure 7 – Phenol portion of Matrixectomy
Partial Nail Avulsion – New Patient
Patient:[Patient.Name]AccountNo: [Patient.AcctNo] Date:[Date]
Chief Complaint:This[Patient.Age]yearold[Patient.Gender] presentstodaywithacomplaintof [an
ingrownnail,aninfectedtoenail,apainful nail,anabscess,aredarea] of the [right, left, bilateral]
[hallux, 2nd
toe,3rd
toe, 4th
toe, 5th
toe, foot, leg].Statesthe problemis[acute, chronic, beenpresentfor
a while butthoughtitwouldresolve onitsown].The patientadmitsto[odor, redness, cleardrainage,
pusdraining, painassociatedwithclosed-toeshoe gear, burning, heat,pain].Previoustreatments:
[antibioticsprescribedbyanotherphysician, self-debridement, soaks, local woundcare, surgical
procedures, nothingasitistoo painful totouch, benignneglect].Patientstatesthisproblemarose from
[an unknowncause, pedicure, trauma, impropercuttingof nails, improperlyfittedshoes, trauma,
swellingof the legsandfeet].
Allergies: [Allergies]

37. 36
Medications:[Meds]
Past Medical History:[PMH]
Past Surgical History:[PSH]
Past FamilyandSocial History:[PFH];[Social History]
Reviewof Systems:
Constitutional:[Constitutional]
ENMT: [ENMT]
Cardiovascular:[CV]
Respiratory:[Respiratory]
GI: [GI]
GU: [GU]
Immunologic:[Immunologic]
Endocrine: [Endocrine]
Hematologic/Lymphatic: [Hematologic/Lymphatic]
Integumentary: [Integumentary]
Musculoskeletal: [MSK]
Neurological: [Neurological]
Psychiatric: [Psychiatric]
Examination:The patientisappropriatelydressed,articulate,awake,alert,andorientedx 3,appears
theirstatedage and appearsto be in goodhealth.Theirvitalsare asfollows:[Vitals].
Dermatological:The [right,left] [1st
digit, 2nd
digit, 3rd
digit, 4th
digit, 5th
digit, foot, ankle, leg] [medial
border, lateral border, entire nail plate] is[erythematous,edematous, withpurulentdrainage, with
serosanginousdrainage, withnodrainage, incurvatedatthe nail fold, hypertrophiedatthe labial nail,
withgranulomatous lesion, loose fromthe nail bedpartially, loose fromthe nail bedcompletely].[No
openlesionsorsignsof bacterial orfungal infectiontothe remainderof eitherfoot].
Neurological:Protective sensation[intact, diminished, absent].Pain[is, isnot] appreciatedtothe area.
Vascular:Dorsalispedisandposteriortibialpulsesare [0, 1, 2, 3, 4]/4 bilateral.Capillaryfillingtime with
the legelevatedis[<5, 5, >5] secondsatthe level of the digital tuftsbilaterally.There [are, are not]
ischemicskinchangesevident.

38. 37
Musculoskeletal: [Muscle strengthforall prime moversof the footare intact bilateral withappropriate
muscle tone andsymmetryandfull range of motionforall jointswithoutcrepitationorinstability
appreciated, muscle weaknessappreciatedasaresultformedical status, limitationof motionand
stiffnessappreciatedasa resultof currentmedical condition].
Impression:[paronychia, severe abscess, symptomaticingrowntoenail, sub-ungalulcer, granuloma,
hematoma, seroma,ulceration, subungual ulcer, cellulitis] [1R, 2R, 3R, 4R, 5R, 1L, 2L, 3L, 4L, 5L, right
foot, rightleg, leftfoot, leftleg][medial border, lateral border, entire nailplate]
Plan: I have discussedthe treatmentoptionswiththe patientanddue tothe nature of the infection,I
recommendedapartial nail avulsionof the offendingnail segment withremoval of all infectedtissue
and hypertrophictissueinthe nail groove.Idiscussedthe risks,complications,andexpectedrecovery
course withthe patientandtheyunderstandthe areamay become symptomaticagaininthe future.
Treatment: Appropriate informedconsentwasobtainedandverificationof the correctdigitwasdone.
[The toe was anesthetizedwith3cc,4cc,5cc,6cc of, a half and half solutionof 0.5% Marcaine™ plainand
1% lidocaine plain,2%lidocaine plain, Noanesthesiawasrequiredas the patientwasinsensate enough
to tolerate the procedure, The digitwaspreppedinthe usual asepticmanner].[A digital tourniquetwas
appliedandremovedatthe endof the procedure, notourniquetwasapplied].A partial avulsionof the
offendingsegmentof nail wasperformedandall granulomatousanddevitalizedtissuewithinthe nail
foldwasremoved.The woundwasthenirrigatedwithhydrogenperoxideanddressedwithbacitracin
and a dry sterile lightlycompressive dressingwasapplied.[The patientwasgivenaprescriptionfor, The
patientwasadvisedtodiscontinuethe medicationif side effectsarise andtonotifythe office
immediatelyforadjustmentof the antibiotics, Antibioticswere notdeemednecessary.] [The
tourniquetwasremoved]. Explicitoral andwrittenpostoperative instructionswere dispensedfordaily
woundcare.We will see the patientinfollow-upin[1week, 11days, 2 weeks, prn] Shouldproblems
arise earlierorsignsand symptomsof infectionworsenthe patientagreesto come tothe office for
evaluation.
Partially Avulsed Nail
Patient:[Patient.Name]AccountNo:[Patient.AcctNo] Date:[Date]
Chief Complaint:This[Patient.Age]yearold[Patient.Gender] presentstodaywithacomplaintof a
[acute, chronic] avulsingnail of the [right,left] [1st
,2nd
,3rd
, 4th
, 5th
] digitwhichispainful andhas not
respondedto[self-debridement, soaks, local woundcare]. Patient[has,hasnot] hada similarcondition
previously.Patientstatesthisproblemarose from[pedicure,trauma,impropercuttingof nails].
Allergies: [Allergies]
Medications:[Meds]
Past Medical History:[PMH]

39. 38
Past Surgical History:[PSH]
Past FamilyandSocial History:[PFSH]
Reviewof Systems:
Constitutionalsymptoms:[Constitutional]
Eyes:[Eyes]
Ears, Nose,Mouth,Throat: [ENMT]
Cardiovascular:[CV]
Respiratory: [Respiratory]
GI: [GI]
GU: [GU]
Musculoskeletal: [MSK]
Integumentary: [Integumentary]
Neurological: [Neurological]
Psychiatric: [Psychiatric]
Endocrine: [Endocrine]
Hematologic/Lymphatic: [Lymphatic]
Allergic/Immunologic:[Immunologic]
Examination:The patientisappropriatelydressed,articulate,awake,alert,andorientedx 3,appears
statedage and looksto be in goodhealth.
Dermatological:The nail of the [right,left][1st
,2nd
,3rd
, 4th
, 5th
] digitispartiallyavulsedwith[hematoma
underthe nail plate,erythema,edema,drainage,odor]. Otherwise,noopenlesionsorsignsof bacterial
or fungal infectiontothe remainderof eitherfoot.
Neurological:Pain isappreciatedtothe offendingnail border.DeeptendonreflexesincludingAchilles
and Patellarare normal,brisk,andsymmetrical bilateral.Epicriticsensationincludingsharp-dull,light
touch,proprioception,2-pointdiscrimination(<12 mm at level of hallux tuft),vibration(128MHz tuning
fork) and protective threshold(10.0gram monofilament) are intactandwithoutfocal motoror sensory
deficitbilateral lowerextremities. Normal musclemassappreciatedtoboththe lowerextremityand
footbilateral.
Vascular:Dorsalispedisandposteriortibialpulsesof the effectedfootare [0, 1, 2, 3, 4]/4 bilateral.
Capillaryfillingtime withthe legelevatedis[<5,5,>5] secondsat the level of the digital tuftsbilaterally.
There are noischemicskinchangesevidenttobilateral lowerextremities.

40. 39
Musculoskeletal:Properalignmenttothe lowerlegs,stableankle tomanual stress(inversionand
anteriordrawer),hindfoot,midfootandforefootbilateral lowerextremities.Muscle strengthforall
prime moversof the lowerleg,ankle,andfootare gradedat 5/5 bilateral lowerextremities.Appropriate
muscle tone andsymmetrybilateral lowerextremities.Full,fluidrange of motionforall jointsfromthe
ankle jointdistal withoutcrepitationorinstabilityappreciatedbilateral lowerextremities.
Impression:[traumaticnail avulsion,ingrowntoenail]
Treatment:Ihave discussedthe treatmentoptionswiththe patientanddue tothe infectednature of
the toe andsevere incurvatednail edgepresentIrecommendedanincisionanddrainage withremoval
of all infectedtissue andthe nail margin.Idiscussedthe risks,complications,andexpectedrecovery
course withthe patientandtheyunderstandthe nail marginwill regrow andmaybecome symptomatic
againin the future. Afterobtainingappropriate informedconsentandverifyingthe correctdigit,the toe
was anesthetizedwith3cc of a half andhalf solutionof 0.5% Marcaine™ plainand1% lidocaine plain
afterwhichthe digitwaspreppedanddrapedinthe usual asepticmanner.Verificationof anesthesia
was performedafterwhichatourniquetwasappliedtothe toe for5-10 minutes.The offendingnail
borderwas removedandirrigatedwithhydrogenperoxide.Bacitracinandadry sterile dressingwas
applied.The tourniquetwasremoved.Explicitoral andwrittenpostoperative instructionswere
dispensed.
Returnto clinicas neededandif problemsarise.
Pigmented Lesion
Patient:[Patient.Name]AccountNo:[Patient.AcctNo] Date:[Date]
Chief Complaint:[Patient.FirstName] isa[Patient.Age] yearold[Patient.Gender] whopresentstoday
witha complaintof a chronicpigmentedlesionwhichhasnotrespondedtosoaksandOTC paddingwith
shoe gearchanges. They[have,have not*] had a similarconditionpreviouslyand denyanyrecent
trauma or incitingevents. Theydonothave a familyhistoryof cutaneousmalignancyandhave nothad
any similarlesionsonthe remainderof theirbodytreatedatany time.
Allergies: [Allergies]
Medications:[Meds]
Past Medical History:[PMH]
Past Surgical History:[PSH]
Past FamilyandSocial History:[PFSH]
Reviewof Systems:

41. 40
Constitutionalsymptoms:[Constitutional]
Eyes:[Eyes]
Ears, Nose,Mouth,Throat: [ENMT]
Cardiovascular:[CV]
Respiratory: [Respiratory]
GI: [GI]
GU: [GU]
Musculoskeletal: [MSK]
Integumentary: [Integumentary]
Neurological: [Neurological]
Psychiatric: [Psychiatric]
Endocrine: [Endocrine]
Hematologic/Lymphatic: [Lymphatic]
Allergic/Immunologic:[Immunologic]
Physical Examination:The patientisappropriatelydressed,articulate,awake,alert,andorientedx 3,
appearstheirstatedage and appearsto be in goodhealth.Vascular:Dorsalispedisandposteriortibial
pulsesare readilypalpable andgradedat2/4 bilateral.Capillaryfilling time withthe legelevatedis<5
secondsat the level of the digital tuftsbilateral.There are noischemicskinchangesevidentof bilateral
lowerextremities.Musculoskeletal:Normal strength,range of motionandalignmentforall jointsfrom
the ankle distal are evidentbilateral. Neurological:DeeptendonreflexesincludingAchillesandPatellar
are normal,brisk,andsymmetrical bilateral.Epicriticsensationincludingsharp-dull,lighttouch,
proprioception,2-pointdiscrimination(<12 mm at level of halluxtuft),vibration(128MHz tuningfork)
and protective threshold(10.0gram monofilament)are intactandwithoutfocal motoror sensorydeficit
bilateral lowerextremities.There are downgoingtoesanda negative clonusbilateral.Normal muscle
mass appreciatedtoboththe lowerextremityandfootbilateral.Dermatological:There isaraised
pigmentedlesiontotheirfoot/toe whichdoesnotshow anycardinal signsof cutaneousmalignancyor
significantirritation. Otherwise,thereisnoevidenceof edema,erythema,ecchymosis,openlesions,
interdigitalmacerationorsignsof bacterial orfungal infectionbilateral lowerextremities. No
varicosities,telangiectasias,orsignsof venousstasischangesof bilateral lowerextremities. Adequate
fat paddingtothe inferioraspectof eachfootis appreciated.
Impression:Symptomaticpigmentedlesion

42. 41
Treatment:Ihave discussedthe treatmentoptionswiththe patientandhave recommendeduse of
Vaselineorsimilarproducttodecrease frictionandeitherpurchasingwider,extra-depthshoe gearor
stretchingtheircurrentshoes. Shouldthesemeasuresfail Irecommendedasimple excisionof the
lesionunderlocal anesthesiaanddiscussedthe risks,complications,andexpectedrecoverycourse in
detail.They will monitorthe lesionandlookforpatrioticsignsof change (i.e.,red,white,bluechanges)
and if presentwill contactme immediately. We will see thembackona PRN basisor soonershould
problemsarise.
Figure 8 - Lesion noted by patient after a training run while wearing joggers
PinPointe - Initial
Patient:[Patient.Name]AccountNo:[Patient.AcctNo] Date:[Date]
Chief Complaint: Discolorationof toenails.Conditionhasexistedfor[several months, overayear, many
years].Condition[is, isnot] painful.Commencement was[insidious, sudden, unsure asnail polishhad
beenonfor so long].Previoustreatmentsinclude:[evaluationbya previousphysician, overthe counter
(OTC) topical agents, prescriptiontopical agents, oral Lamisilinpulse dose, oral Lamisil infull dose, laser
treatments, overthe counter(OTC) remedies, notreatmentadministered].[Patienthasa historyof
complicationswithoral medicines.]

43. 42
Allergies: [Allergies]
Medications:[Meds]
Past Medical History:[PMH]
Past Surgical History:[PSH]
Past FamilyandSocial History:[PFH] [Social History]
Reviewof Systems:
Eyes:[Eyes]
GI: [GI]
GU: [GU]
Gynecological:[Gynecological]
Musculoskeletal: [MSK]
Integumentary: [Integumentary]
Neurological: [Neurological]
Psychiatric: [Psychiatric]
Endocrine: [Endocrine]
Physical Exam:[Vitals]
Vascular: Dorsalispedisare gradedat[1,2,3,5,4] andposteriortibial pulsesare gradedat[1,2,3,5,4] with
digital hairgrowth[present,absent] bilateral. CFTwiththe legelevatedwas[lessthan3 seconds,3
seconds,more than3 seconds] atthe distal toesbilateral. There [is,isnot] evidence of ischemicskin
changes.Temperature fromthe tibiatothe toesis[warm, cool] at anteriortibiato [warm, cool] atthe
distal digitsbilateral.
Neurological: [CoordinationWNLtorightand leftlowerextremity] [Touchsensationsare withinnormal
limits]
Dermatological: There isnail [thickening, elongation, splitting, discoloration,incurvation] of [Hot
Spots]. [There isnormal texture,temperature,turgorandcolorof the skin.] [There isevidence of
peeling,scaling,andchronicdrynessof the skin]
Musculoskeletal: Patientis[able towalkwithease,able towalkwithawalker, inawheelchair]. [Stable
footposture withoutobviousstructural deformitiesnotedbilateral,malpositionof footstructure atthe

44. 43
level of the forefoot, malpositionof footstructure atthe level of the mid-foot, malpositionof foot
structure at the level of the rear-foot, malpositionof footstructure atthe level of the ankle].
Impression: [Onycomycosis, hammertoes, tineapedis, onychogryphosis, ingrowntoenail]
Plan: We discussedtreatmentof onychomycosis.We discussedtopical treatments,oral treatments,and
lasertreatmentsusingthe PinPointelaser. Afterdiscussingthe options,the patientdecidedtotreat the
onychomycosiswithPinPointe laser. The patientsignedthe consentformforthe treatment,andwas
advisednottopainttoenails, duringtreatmentperiod,forthe nextseveral months.Patientwasadvised
not to use nail salon,andnot topluck any material outfromunderthe nail edge.A photographwas
takenof affectednails.[Manual andmechanical debridementof the mycoticnailswascarriedout.] The
laserprocedure wasperformedon[all, bothhalluxnails,1R,2R,3R,4R,5R,1L,2L,3L,4L,5L] nailswithout
complications.The patientwaslectured onthe importance of practicingpreventive measures, and
writteninstructionswere given.Idispensedacomplimentaryantifungal spraytouse intheirshoes, and
an antifungal creamtouse two timesaday for twoweeks,oruntil the skinisclearof infection.Theyare
thento continue usingthe creamtwice weeklyasa lifestyle. Idiscussedcleansingthe showerswith
householdbleachandwashingall socksandbedsheetsinbleach.All questionsanswered.The patient
will RTCin [1 month,2months,3months,4months, PRN] forfollow-upinspectionandphotographs.
Figure 9 – Pinpoint laser producer

45. 44
Figure 10 – After application of Pinpoint
Figure 11 - PinPointe Laser machine
PinPointe - Follow-up
Patient: [Patient.Name] Account No: [Patient.AcctNo] Date: [Date]
Chief Complaint:Thispatientreturnsforfollow upafterthe firstPinPointe lasertreatmentfor
onychomycosis.The patient[is,isnot,intermittently] practicingthe preventivemeasurestoavert
reinfectionbyusing[antifungal creamonthe skin,antifungal oilonthe nails,sprayingshoeswith
Antifungal spray].The patient[has,hasnot] noticedasignificantimprovementinthe nail discoloration
and texture.

46. 45
Physical Examination: There is[normal, abnormal] textureandcolorof the periungual skin. Plantar
skinis[clearof infection, improvedinappearance of infection, notimprovedinappearance of infection].
Nailsare [improvingasexpected, improvingfasterthanexpected, improvingslowerthanexpected, not
improving, worsening, resolvedinappearance of infection]
Assessment: [onychomycosis, tinea pedis] [improving, unchanged, worsening, resolved]
Plan: We discussedthe progress.Photographswere takentodocumentprogress.Patient waslectured,
stressingthe importance of [continuingto practice preventivemeasuresusingthe same overthe
counter(OTC) products, becomingmore aggressiveandmovingtoa prescriptionstrengthproduct].
[Retreatmentwiththe PinPointe laserappliedtothe toenailsinareasthatappearto be infectedwith
fungus.]
RTC [1 month, 2 months, 5 months, PRN] for follow-up inspection.
Ulceration - Initial Visit
Patient:[Patient.Name]AccountNo:[Patient.AcctNo] Date:[Date]
Chief Complaint: This[Patient. Age] yearold[Patient. Gender] presentstodaywithan ulceration.The
ulcerhas beenpresentforseveral [days,weeks,months,years].The conditionis[worsening,
unchanged,improving].Patient[hasrespondedto,hasnotrespondedto,hasnotattempted] local
woundcare.Last seenbyPCP,[Patient. Primary Physician] on[Patient. Date LastSeen].
Allergies: [Allergies]
Medications:[Meds]
Past Medical History:[PMH]
Past Surgical History:[PSH]
Past FamilyandSocial History:[PFH] [Social History]
Reviewof Systems:
Constitutional:[Constitutional]
ENMT: [ENMT]
Cardiovascular:[CV]
Respiratory:[Respiratory]
GI: [GI]