Homework SOAP notes
SOAP
S
Patient reports pain in the plantar region of the right foot when getting out of bed in the morning, rated as 8/10 on the pain scale. Pain decreases throughout the day when walking, but increases when sitting for a long time and when standing up to step the pain returns. There is no previous history of foot injuries. He reports that he has started running.
O
Swelling around the right heel is observed, tenderness upom palpation in the plantar region from the heel to the toes. Muscle strength tests indicate 4/5 of the plantar flexors and dorsiflexors. Range of motion is not affected and without change during gait assessment.
A
The findings are consistent with plantar fasciitis, probably due to the onset of running and inappropriate use of sneakers.
P
Provide guidance on proper use of running shoes, ice application and initiate a program to strengthen the plantarflexor and dorsiflexor muscles, stretch the plantar fascia and release myofascially. Recommend follow-up in two weeks to assess progress
2
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Erika Giselle M P Castanheira
1
Homework SOAP notes
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