ICD-10 Chief Complaint:
Physical Exam:
General Appearance: Well-nourished, well developed in no acute distress. Orientation: Oriented to person, place and time. Mood / Affect: Calm. Gait: antalgic Coordination: normal Ankle / foot Exam (Bilateral). Inspection / Palpation LE (R/L): nontender. Dorsiflexion (R/L): 25º / 25º. Plantarflexion (R/L): 50º / 50º. Strength LE: 5/5 EHL, tibialis anterior, plantar flexion bilaterally. Sensation: subjective normal distal sensation bilateral LE. Vasculature: <2 second distal capillary refill bilaterally. Skin and lymph: appears normal in the affected extremity.
Diagnostic Studies:
Xray series of the foot including A/P, lateral and oblique views taken today was personally evaluated by me and demonstrates the following: Fracture (s) and/or Dislocation(s): None . Alignment: Normal . Joint space(s): Normal . Soft tissues: Normal .
Assessment:
M79.671 Pain in right foot
Plan:
Discussed natural history, operative and non-operative treatments; risks, benefits and expected rehab course of each. All questions were answered.
Category:
- Musculoskeletal System
ICD-10:
M79.671
ICD:
M79
Side:
- Right
ICD-10CM Year:
2019