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Received INITIAL PODIATRIC CONSULTATION AND EVALUATION REPORT FROM FOOT SPECIALIST - Printable Version

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Received INITIAL PODIATRIC CONSULTATION AND EVALUATION REPORT FROM FOOT SPECIALIST - Sunshine7 - 01-11-2010

Vascular: The patient's skin temperature was warm, bilaterally and symmetrically. Hair growth was present, bilaterally and symmetrically. Anterior tibial pulses and posterior tibial pulses were 2 + 4 and palpable bilaterally. The capillary fill time was less than 3 seconds, bilaterally. No vascular lesions were noted. No cyanosis or rubor noted.
Dermatological: The patient's skin texture and turgor was within normal limits. The nails of all digits were within normal limits for digits one through five. There was no active bleeding, purulince or odor. No other overt laccerations or ulcerations were present. Skin tone and color were within normal limits. She does have mild onychomycosis on the hallux nail.
Neurological: Significant symptomatologies regarding the foot and the leg, with significant peroneal nerve symptons persisting for the patient radiating down the foot with positive Tinel. Mild Valleix sign radiating up into the leg but demonstrates significant findings with ambulation and weightbearing.
Muscle strength: Muscle testing is weak and difficult to test secondary to the pain she continues to have with 4/5 range of motion on the right side and 5/5 on the left side.


RE: Received INITIAL PODIATRIC CONSULTATION AND EVALUATION REPORT FROM FOOT SPECIALIST - Sunshine7 - 01-11-2010

Orthopedic examination: The patient was examined. The patient presenting unable to ambulate on the foot at all. The patient was unable to walk at all and stand at all. No toe walking and no toe standing, heel walking, heel standing, squatting, and crouching on the right foot side. Demonstrates difficulty with single-limb weightbearing and ambulates with crutches. Demonstrates severe pain and hypersensitivity with withdrawl reflex, and grimacing and crying on touching, palpation, and range of motion of the right foot. Symptomatically, the patient presents with findings that are consistent with symptoms of complex regional pain syndrome versus early RSD symptomatologies. The patient does present to the office today demonstrating range of motion of the right foot demonstrating extreme restriction secondary to prolonged disuse and non-use with range of motion as follows: RIGHT LEFT
DORSIFLEXION 10 20
PLANTAR FLEXION 15 40
INVERSION 5 25
EVERSION 5 15


RE: Received INITIAL PODIATRIC CONSULTATION AND EVALUATION REPORT FROM FOOT SPECIALIST - Sunshine7 - 01-11-2010

REVIEW OF SUBMITTED MEDICAL RECORDS
Review of medical records which are extensive include the initial evaluation and re-evaluations with of my doctors notes and review of the EMG/NCV demonstrating right peroneal axonal neuropathy as well Dr. report based on the EMG/NCV studies, confirming neurological deficits as well as possible S1 radiculopathy with right peroneal nerve axonal neuropathy as well as the MRI of the right foot consistent with injury in first metatarsophalangeal joint, joint effusion with dorsal capsule structures, Review of those films by myself also confirmed the above findings with a tear of the dorsal capsule of the leg.
DIAGNOSES:
1. COMPLEX REGIONAL PAIN SYNDROME OF THE RIGHT LOWER EXTREMITY.
2. CONTUSION AND CRUSH INJURY OF THE RIGHT FOOT.
3. NEURITIS
4. PAINFUL GAIT
My med. dr. changed my meds to percocet 10/325 and trazodone 50 mg. He also told the secretaries to get a pain manager appt. for me he care you can tell.
CAUSATION: IT APPEARS THAT THE INJURIES SUSTAINED BY THE PATIENT WERE THE BASIS OF AN INDUSTRIAL INJURY RESULTING IN THE ABOVE DIAGNOSES.


RE: Received INITIAL PODIATRIC CONSULTATION AND EVALUATION REPORT FROM FOOT SPECIALIST - Sunshine7 - 01-11-2010

Please help me understand this report thanks so much! Have a wonderful day!


RE: Received INITIAL PODIATRIC CONSULTATION AND EVALUATION REPORT FROM FOOT SPECIALIST - Cycler - 01-11-2010

What don't you understand ? Seems to meet the diagnostic criteria of major causalgia but only very few of the typical CRPs Type I diagnostic criteria - allodynia being about it. Consistent with a primary nerve injury maybe ?

http://en.wikipedia.org/wiki/Complex_regional_pain_syndrome


RE: Received INITIAL PODIATRIC CONSULTATION AND EVALUATION REPORT FROM FOOT SPECIALIST - inpainokla - 01-11-2010

cycler what do you do for a living are you in the medical feild"?


RE: Received INITIAL PODIATRIC CONSULTATION AND EVALUATION REPORT FROM FOOT SPECIALIST - inpainokla - 01-11-2010

the only reason i ask is because you know alot about everything


RE: Received INITIAL PODIATRIC CONSULTATION AND EVALUATION REPORT FROM FOOT SPECIALIST - Sunshine7 - 01-11-2010

Thanks Cycler I wasn't sure what stage I'm at, have a nice evening.


RE: Received INITIAL PODIATRIC CONSULTATION AND EVALUATION REPORT FROM FOOT SPECIALIST - chrischris - 01-12-2010

Sunshine,
The diagnosis area is really the bottom line and everything else is just long winded terminology leading to the diagnosis. If you are really curious about the medical words that you don't understand, just take a small section at a time and look the words up in wikipedia.com. Your doctor may be willing to go into more detail, or if you have a NCM assigned to your case, that would be a good source to ask.

Here are a couple of RSD sites that will help you learn about your condition.

http://rsds.org
http://www.rsdhope.org
http://www.forgrace.org

If you tell me what part of California you are in, I might be able to help you with a good RSD doctor referral.


RE: Received INITIAL PODIATRIC CONSULTATION AND EVALUATION REPORT FROM FOOT SPECIALIST - kit - 01-12-2010

Tabers medical dictionary will also give you definitions of the medical jargon.