10 Common Podiatry SOAP Note Examples

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List of cases

1. Plantar Fasciitis
2. Diabetic Foot Ulcer
3. Ingrown Toenail
4. Bunion Deformity
5. Ankle Sprain
6. Achilles Tendinitis
7. Morton's Neuroma
8. Heel Spur
9. Fungal Nail Infection
10. Metatarsalgia

1. Plantar Fasciitis

Description

The patient presents with chronic heel pain consistent with plantar fasciitis.

SOAP Note

Patient Name: Michael Roberts

Date of Visit: 09/01/2024

Subjective

Michael Roberts, a 45-year-old male retail manager, presents with 3-month history of left heel pain. Pain worst with first steps in morning and after prolonged standing. Pain rated 7/10 in morning, improving to 4/10 during day. Recently started jogging program. Tried OTC insoles with minimal relief. No previous foot injuries. Works 8-hour shifts on concrete floors.

Objective

• Vital Signs:
  • BP: 124/78 mmHg
  • HR: 72 bpm
  • RR: 16/min
  • Temp: 98.6°F
  • Weight: 85 kg
  • BMI: 27.4
• Physical Exam:
  • Inspection:
    • No gross deformity
    • Normal arch height
    • No edema
    • No erythema
  • Palpation:
    • Tender at plantar fascia origin
    • Pain with windlass test
    • No calcaneal squeeze tenderness
  • Range of Motion:
    • Ankle dorsiflexion limited to 5°
    • Plantar flexion WNL
    • Pain with toe extension
  • Gait Analysis:
    • Antalgic gait
    • Early heel lift
    • Decreased stance phase
• Imaging:
  • X-ray: No fracture or spur
  • Ultrasound: Plantar fascia 5.2mm

Assessment

1. Plantar Fasciitis, Left Foot
   • Chronic presentation
   • Biomechanical factors
   • Work-related aggravation
2. Ankle Equinus
   • Contributing to symptoms
   • Requires stretching

Plan

1. Treatment:

   • Custom orthotics ordered
   • Night splint prescribed
   • Activity modification
   • CPT Code: 99203

2. Medications:

   • Meloxicam 15mg daily
   • Topical diclofenac gel
   • Ice massage instructions

3. Physical Therapy:

   • Stretching exercises
   • Gastrocnemius/soleus
   • Plantar fascia specific
   • Home program provided

4. Follow-up:

   • 3 weeks follow-up
   • Orthotic fitting
   • Consider injection if no improvement

2. Diabetic Foot Ulcer

Description

The patient presents for evaluation and treatment of a diabetic foot ulcer.

SOAP Note

Patient Name: Patricia Thompson

Date of Visit: 09/02/2024

Subjective

Patricia Thompson, a 62-year-old female with type 2 diabetes (15-year history), presents with non-healing ulcer on right plantar heel of 3 weeks duration. Noticed after wearing new shoes. Denies trauma. Blood sugars ranging 150-200mg/dL. Previous history of ulceration 2 years ago. Reports adequate offloading with provided wheelchair.

Objective

• Vital Signs:
  • BP: 138/84 mmHg
  • HR: 78 bpm
  • RR: 16/min
  • Temp: 98.6°F
  • Weight: 78 kg
  • BMI: 29.2
• Physical Exam:
  • Wound Assessment:
    • 2.0 x 1.5 cm ulcer
    • Wagner Grade 2
    • Depth 0.4 cm
    • No undermining
    • Pink wound bed
    • Minimal exudate
  • Vascular:
    • Pulses: DP 1+, PT 1+
    • Capillary refill 3 seconds
    • Skin temperature normal
  • Neurological:
    • Absent 10g monofilament
    • Diminished vibratory sense
    • Absent ankle reflexes
  • Dermatological:
    • Skin dry, intact
    • No maceration
    • Periwound callus
• Laboratory:
  • HbA1C: 8.2%
  • WBC: 8.5 K/μL
  • ESR: 22 mm/hr

Assessment

1. Diabetic Foot Ulcer
   • Wagner Grade 2
   • Neuropathic etiology
   • No clinical infection
2. Peripheral Neuropathy
   • Diabetes-related
   • High risk for complications

Plan

1. Treatment:

   • Sharp debridement
   • Wound care protocol
   • Offloading device
   • CPT Code: 11042, 99213

2. Wound Care:

   • Collagen dressing
   • Foam secondary dressing
   • Daily dressing changes
   • Total contact cast

3. Patient Education:

   • Diabetes management
   • Foot inspection
   • Proper footwear
   • Warning signs

4. Follow-up:

   • Weekly wound checks
   • Vascular studies ordered
   • Endocrinology referral

3. Ingrown Toenail

Description

The patient presents with painful ingrown toenail of the right hallux with signs of infection.

SOAP Note

Patient Name: Emily Chen

Date of Visit: 09/03/2024

Subjective

Emily Chen, a 24-year-old female, presents with 2-week history of painful right great toe. Pain rated 8/10, worse with pressure and wearing shoes. Attempted home care with soaking and trimming. Reports previous episodes. No history of diabetes. Works as a waitress. Denies recent trauma.

Objective

• Vital Signs:
  • BP: 118/72 mmHg
  • HR: 76 bpm
  • RR: 16/min
  • Temp: 98.8°F
  • Weight: 60 kg
• Physical Exam:
  • Inspection:
    • Medial nail border embedded
    • Surrounding erythema
    • Granulation tissue present
    • Moderate hypertrophy
  • Palpation:
    • Severe tenderness
    • Warmth present
    • Fluctuance noted
  • Nail Assessment:
    • Medial border penetration
    • Stage 3 classification
    • Purulent drainage
  • Vascular:
    • Pulses 2+ DP/PT
    • Capillary refill less than 2 seconds
    • Good tissue perfusion

Assessment

1. Onychocryptosis, Right Hallux
   • Stage 3 with infection
   • Medial border involvement
   • Failed conservative care
2. Paronychia
   • Secondary to ingrowth
   • Moderate severity

Plan

1. Treatment:

   • Partial nail avulsion
   • Matricectomy planned
   • Local anesthesia
   • CPT Code: 11730, 11732

2. Medications:

   • Cephalexin 500mg QID x7 days
   • Ibuprofen 600mg TID prn
   • Topical bacitracin

3. Patient Education:

   • Proper nail trimming
   • Footwear modification
   • Post-op care instructions
   • Prevention strategies

4. Follow-up:

   • 48-hour wound check
   • Remove packing
   • Weekly until healed

4. Bunion Deformity

Description

The patient presents for evaluation of progressive bunion deformity with increasing pain.

SOAP Note

Patient Name: Sarah Miller

Date of Visit: 09/04/2024

Subjective

Sarah Miller, a 52-year-old female, presents with worsening left bunion pain of 2 years duration. Pain rated 6/10, worse with dress shoes and prolonged walking. Conservative measures including wider shoes and padding provide minimal relief. Family history positive for bunions. No previous foot surgery.

Objective

• Vital Signs:
  • BP: 122/76 mmHg
  • HR: 74 bpm
  • RR: 16/min
  • Temp: 98.6°F
  • Weight: 65 kg
• Physical Exam:
  • Inspection:
    • Prominent medial eminence
    • Hallux valgus deformity
    • No overlapping toes
    • Mild erythema over bunion
  • Range of Motion:
    • First MPJ: 20° dorsiflexion
    • Pain at end range
    • Crepitus noted
  • Gait Analysis:
    • Apropulsive gait
    • Decreased toe-off
    • Modified shoe wear
  • Measurements:
    • HVA: 32 degrees
    • IMA: 15 degrees
    • Sesamoid position: Grade 2
• Imaging:
  • X-rays: Weight-bearing AP/Lateral/Oblique
  • Moderate joint space narrowing
  • No arthritis noted

Assessment

1. Hallux Valgus Deformity
   • Moderate severity
   • Progressive symptoms
   • Failed conservative care
2. First MPJ Dysfunction
   • Limited ROM
   • Biomechanical impact
   • Compensatory changes

Plan

1. Treatment:

   • Surgical consultation
   • Pre-op planning
   • Conservative measures
   • CPT Code: 99213

2. Conservative Care:

   • Custom orthotics
   • Bunion splint night wear
   • Toe spacers
   • Proper shoe fitting

3. Patient Education:

   • Surgical options discussed
   • Risk/benefit review
   • Recovery expectations
   • Activity modifications

4. Follow-up:

   • 2 weeks for surgical planning
   • Continue conservative care
   • Pre-op testing if elected

5. Ankle Sprain

Description

The patient presents with acute left ankle injury following sports activity.

SOAP Note

Patient Name: Marcus Johnson

Date of Visit: 09/05/2024

Subjective

Marcus Johnson, a 28-year-old male basketball player, presents with acute left ankle injury sustained 2 hours ago during a game. Mechanism was inversion while landing from a jump. Immediate pain and swelling noted. Pain rated 8/10, worse with weight bearing. Able to walk with significant limp. No previous ankle injuries. Ice applied at site.

Objective

• Vital Signs:
  • BP: 126/78 mmHg
  • HR: 82 bpm
  • RR: 16/min
  • Temp: 98.6°F
  • Weight: 85 kg
• Physical Exam:
  • Inspection:
    • Moderate lateral swelling
    • Ecchymosis developing
    • No gross deformity
    • Normal arch height
  • Palpation:
    • Tender over ATFL/CFL
    • Pain lateral malleolus
    • No medial tenderness
  • Range of Motion:
    • Dorsiflexion limited
    • Painful inversion
    • Eversion intact
  • Special Tests:
    • Positive anterior drawer
    • Positive talar tilt
    • Negative Ottawa criteria
• Neurovascular:
  • Sensation intact
  • Pulses 2+ DP/PT
  • Cap refill less than 2 seconds

Assessment

1. Grade II Lateral Ankle Sprain
   • Acute presentation
   • Ligamentous injury
   • No fracture suspected
2. Peroneal Strain
   • Secondary to injury
   • Mild severity

Plan

1. Treatment:

   • RICE protocol
   • CAM walker boot
   • Protected weight bearing
   • CPT Code: 99203

2. Medications:

   • Naproxen 500mg BID
   • Acetaminophen prn pain
   • Topical ice therapy

3. Physical Therapy:

   • Early mobilization
   • Strengthening program
   • Balance training
   • Home exercise plan

4. Follow-up:

   • 1 week follow-up
   • PT referral given
   • Return to play protocol

6. Achilles Tendinitis

Description

The patient presents with chronic Achilles tendon pain affecting athletic activities.

SOAP Note

Patient Name: Rachel Foster

Date of Visit: 09/06/2024

Subjective

Rachel Foster, a 35-year-old female runner, presents with 6-week history of left Achilles pain. Pain worst in morning and after running. Recently increased mileage for marathon training. Pain rated 5/10, improves with warm-up. Previous episode 2 years ago resolved with PT. Currently running 30 miles/week.

Objective

• Vital Signs:
  • BP: 118/74 mmHg
  • HR: 68 bpm
  • RR: 16/min
  • Temp: 98.6°F
  • Weight: 58 kg
• Physical Exam:
  • Inspection:
    • Mild fusiform swelling
    • No erythema
    • Normal alignment
    • 2cm proximal to insertion
  • Palpation:
    • Tenderness mid-portion
    • No nodules
    • No crepitus
  • Range of Motion:
    • Ankle DF: 10°
    • PF: Full but painful
    • Subtalar motion WNL
  • Special Tests:
    • Positive Thompson squeeze
    • Pain with single heel raise
    • Royal London test positive
• Imaging:
  • Ultrasound: 6.8mm thickness
  • No rupture or tear
  • Moderate hypervascularity

Assessment

1. Achilles Tendinopathy
   • Mid-portion involvement
   • Activity-related
   • Chronic presentation
2. Training Error
   • Sudden mileage increase
   • Contributing factor

Plan

1. Treatment:

   • Activity modification
   • Eccentric protocol
   • Heel lifts provided
   • CPT Code: 99213

2. Medications:

   • Meloxicam 15mg daily
   • Topical diclofenac
   • Ice after activity

3. Physical Therapy:

   • Eccentric loading program
   • Manual therapy
   • Gait analysis
   • Training modification

4. Follow-up:

   • 3 weeks follow-up
   • Monitor progress
   • Gradual return to running

7. Morton's Neuroma

Description

The patient presents with forefoot pain consistent with Morton's neuroma.

SOAP Note

Patient Name: Linda Parker

Date of Visit: 09/07/2024

Subjective

Linda Parker, a 48-year-old female office worker, presents with 4-month history of right forefoot pain. Describes sharp, burning pain between 3rd and 4th toes, worse with dress shoes and high heels. Pain rated 6/10, relieved by removing shoes. Reports sensation of "walking on a pebble." No previous foot surgery. Works in heels frequently.

Objective

• Vital Signs:
  • BP: 120/76 mmHg
  • HR: 74 bpm
  • RR: 16/min
  • Temp: 98.6°F
  • Weight: 63 kg
• Physical Exam:
  • Inspection:
    • No visible deformity
    • Normal alignment
    • No edema
    • No color changes
  • Palpation:
    • Mulder's click positive
    • Web space tenderness
    • No masses palpable
  • Range of Motion:
    • Metatarsophalangeal joints WNL
    • Pain with compression
    • No crepitus
  • Neurological:
    • Decreased sensation web space
    • Normal muscle strength
    • DTRs symmetric
• Imaging:
  • Ultrasound: 6mm neuroma
  • X-rays: Normal alignment

Assessment

1. Morton's Neuroma
   • 3rd interspace
   • Moderate severity
   • Mechanical aggravation
2. Footwear Contributing
   • High heel use
   • Narrow toe box

Plan

1. Treatment:

   • Metatarsal pad placement
   • Shoe modification
   • Activity adjustment
   • CPT Code: 99213

2. Medications:

   • Gabapentin 300mg TID
   • NSAIDs as needed
   • Consider injection

3. Patient Education:

   • Proper shoe fitting
   • Activity modification
   • Ergonomic workplace
   • Self-management

4. Follow-up:

   • 3 weeks follow-up
   • Consider injection
   • Surgical options if needed

8. Heel Spur

Description

The patient presents with chronic heel pain associated with calcaneal spur.

SOAP Note

Patient Name: Robert Wilson

Date of Visit: 09/08/2024

Subjective

Robert Wilson, a 55-year-old male construction worker, presents with 6-month history of right heel pain. Pain worst with first steps and after prolonged standing. Pain rated 7/10 in morning, 5/10 during day. Previous cortisone injection provided temporary relief. Tried OTC arch supports without improvement. Works on concrete surfaces.

Objective

• Vital Signs:
  • BP: 132/82 mmHg
  • HR: 76 bpm
  • RR: 16/min
  • Temp: 98.6°F
  • Weight: 90 kg
  • BMI: 28.6
• Physical Exam:
  • Inspection:
    • Normal foot alignment
    • No edema
    • No erythema
    • Pes planus noted
  • Palpation:
    • Plantar calcaneal tenderness
    • Medial tubercle pain
    • No lateral pain
  • Range of Motion:
    • Ankle ROM WNL
    • STJ pronation increased
    • First MPJ ROM normal
  • Gait Analysis:
    • Apropulsive gait
    • Early heel lift
    • Overpronation
• Imaging:
  • X-ray: 8mm plantar heel spur
  • Increased soft tissue density

Assessment

1. Calcaneal Spur Syndrome
   • Chronic presentation
   • Associated plantar fasciitis
   • Work aggravation
2. Pes Planus
   • Contributing factor
   • Biomechanical influence

Plan

1. Treatment:

   • Custom orthotics ordered
   • Night splint prescribed
   • Work modifications
   • CPT Code: 99213

2. Medications:

   • Diclofenac 75mg BID
   • Consider cortisone injection
   • Ice therapy protocol

3. Physical Therapy:

   • Stretching program
   • Taping technique
   • Strengthening exercises
   • Manual therapy

4. Follow-up:

   • 2 weeks follow-up
   • Injection if needed
   • Orthotic fitting

9. Fungal Nail Infection

Description

The patient presents for evaluation and treatment of chronic toenail fungal infection.

SOAP Note

Patient Name: Carol Martinez

Date of Visit: 09/09/2024

Subjective

Carol Martinez, a 58-year-old female, presents with progressive thickening and discoloration of multiple toenails over past year. Most concerned about right great toenail. Reports occasional discomfort with shoes. Previous over-the-counter antifungal treatments ineffective. Regular gym user. No previous nail surgery. Family history of similar condition.

Objective

• Vital Signs:
  • BP: 124/76 mmHg
  • HR: 72 bpm
  • RR: 16/min
  • Temp: 98.6°F
  • Weight: 70 kg
• Physical Exam:
  • Nail Assessment:
    • Subungual hyperkeratosis
    • Yellow-brown discoloration
    • 80% nail plate involvement
    • 4mm thickness hallux
  • Additional Findings:
    • Multiple nails affected
    • No paronychia
    • Intact surrounding skin
  • Pedal Pulses:
    • DP/PT 2+ bilateral
    • Normal capillary refill
  • Dermatological:
    • Mild tinea pedis
    • Web spaces clear
    • No maceration
• Laboratory:
  • KOH preparation: Positive
  • Fungal culture pending

Assessment

1. Onychomycosis
   • Distal subungual type
   • Multiple nail involvement
   • Chronic presentation
2. Tinea Pedis
   • Mild presentation
   • Contributing factor

Plan

1. Treatment:

   • Oral terbinafine prescribed
   • Nail debridement
   • Topical therapy
   • CPT Code: 11721

2. Medications:

   • Terbinafine 250mg daily x12 weeks
   • Ciclopirox nail lacquer
   • Antifungal cream for feet

3. Patient Education:

   • Proper foot hygiene
   • Shoe sanitization
   • Prevention strategies
   • Treatment timeline

4. Follow-up:

   • Monthly nail measurements
   • Monitor LFTs
   • 12-week course review

10. Metatarsalgia

Description

The patient presents with chronic forefoot pain consistent with metatarsalgia.

SOAP Note

Patient Name: James Anderson

Date of Visit: 09/10/2024

Subjective

James Anderson, a 45-year-old male sales representative, presents with 3-month history of bilateral ball-of-foot pain. Pain worse with dress shoes and prolonged walking. Describes aching and burning sensation. Pain rated 6/10 by end of day. Previous use of gel insoles provided minimal relief. Spends long hours on feet at trade shows.

Objective

• Vital Signs:
  • BP: 128/78 mmHg
  • HR: 76 bpm
  • RR: 16/min
  • Temp: 98.6°F
  • Weight: 82 kg
• Physical Exam:
  • Inspection:
    • Normal foot alignment
    • No digital deformities
    • Mild forefoot edema
    • Callus formation
  • Palpation:
    • 2nd/3rd MPJ tenderness
    • Plantar forefoot pain
    • No masses noted
  • Range of Motion:
    • MPJ ROM limited
    • Pain with dorsiflexion
    • No crepitus
  • Gait Analysis:
    • Early heel lift
    • Decreased propulsion
    • Antalgic pattern
• Imaging:
  • X-rays: Normal alignment
  • No arthritis or fracture
  • Preserved joint spaces

Assessment

1. Metatarsalgia
   • Primary mechanical
   • Bilateral involvement
   • Work-related aggravation
2. Forefoot Overload
   • Occupational factors
   • Improper footwear

Plan

1. Treatment:

   • Custom orthotics ordered
   • Metatarsal padding
   • Activity modification
   • CPT Code: 99213

2. Medications:

   • Meloxicam 15mg daily
   • Topical diclofenac
   • Ice therapy protocol

3. Patient Education:

   • Proper shoe selection
   • Work modifications
   • Weight management
   • Activity pacing

4. Follow-up:

   • 3 weeks follow-up
   • Orthotic fitting
   • Review work ergonomics