SOAP Note Template copy 2 PDF

Title SOAP Note Template copy 2
Author Μιχαλης Αριστοδημου
Course Injury Evaluation I
Institution Nova Southeastern University
Pages 1
File Size 35.1 KB
File Type PDF
Total Downloads 90
Total Views 165

Summary

The 26-year-old 100m sprinter has height of 1.80m and weight 70k. He had a knee ACL sprain back in 2008 but since then he doesn’t have any other injuries or any health issues. He didn’t felt any pain during practice but at the end his foot started bothering him. The pain was worst the day after he w...


Description

ATTR 2100 Template Name:

Nick Cassata

Date of Injury:

27/8/15

Sport:

Sprinter (100m)

Date of Evaluation:

29/8/15

Body Part:

Left Ankle

Primary Complaint:

Pain under the foot

Subjective: The 26-year-old 100m sprinter has height of 1.80m and weight 70k. He had a knee ACL sprain back in 2008 but since then he doesn’t have any other injuries or any health issues. He didn’t felt any pain during practice but at the end his foot started bothering him. The pain was worst the day after he woke up. The pain is worst when he is walking (push off gait). He describes the pain as “sharp” with a pain scale of 7/10 under the foot and even more pain after resting periods 8/10.

Objective: Through palpation the pain is located near the origin of the plantar fascia. Significant swelling in the injured leg (2 inches more circumference compared bilaterally) and elevated temperature near the calcaneus is determined through palpation. Decreased AROM when DF, increase of pain when reach 20 degrees. PROM pain 7/10 when PF. MMT 4/5 when DF, 5/5 when PF. Tinel’s sign: (-), Windlass test (+) Cap refill: WNL Neurological test: WNL

       

Assessment:

Plan:

IMP: Plantar Fasciitis DD: Jones fracture, Calcaneus fracture

   

Rest Ice Compression Elevation

Evaluator:

Michalis Aristodemou

Signature:

Michalis Aristodemou

Date:

29/8/15...


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