PATIENT: OWEN, MAXINE ACCOUNT/EHR #: OWENMA001 DATE:

PATIENT: OWEN, MAXINE ACCOUNT/EHR #: OWENMA001 DATE: 10/15/18 This new patient is a 25-year-old female who presents with a 9-year history of rheumatoid arthritis and extreme pain and deformity of the forefoot. Whereas both feet are painful, she says the right foot is more severe than the left. The patient says the pain is in the region of the lateral fourth and fifth metatarsal heads and in the metatarsophalangeal joints (MPJ) of toes two through five. The pain has gotten worse in the past 2 years, and she has trouble with shoes that are not soft and very cushioned. She has tried custom insoles to accommodate the plantar fourth and fifth metatarsal region without much relief. She is currently taking methotrexate and NSAIDs for her pain and rheumatoid arthritis control. EXAM: Stable and intact neurovascular testing. The forefoot is slightly laterally deviated, and there is severe hammertoe deformity of toes two through five of both feet. The main pain is located plantar to the fourth and fifth metatarsal heads with mild pain in the region of a hallux valgus deformity. The contraction of the toes is mildly reducible, yet the main deforming force occurs with dorsal contracture of the extensor tendons and skin on the dorsum of the foot. Attempting to reduce the digits relieves much of the plantar MPJ contraction and deformity, yet there is continued plantar prominence of the metatarsal heads, especially on the lateral side of the foot. There is a mild equinus deformity of the ankle with a tight Achilles tendon noted on both the straight and bent knee exam. There is a high arch with midfoot contracture, yet this does not seem to be excessive and reduces well with dorsal midfoot pressure and a standing position. The patient’s gait pattern reveals severe extensor substitution with dorsal pull of the extensor tendons at the associated MPJ. TESTING: X-rays, 2 views, show mild MPJ dislocation with severe hammertoes and associated hallux valgus deformity of the digits. There is also some osteopenia of the metatarsal heads. Her foot alignment reveals a mild anterior cavus with excellent rearfoot alignment and no signs of degenerative joint disease. ASSESSMENT: This patient’s rearfoot is stable except for an underlying mild equinus deformity. The main part of the patient consent is for the underlying hallux valgus correction with osteotomy, hammertoe correction of all toes with extensor tendon transfer to the metatarsal heads, and a V-Y lengthening of the dorsal skin contracture. The consent also includes possible metatarsal osteotomies of metatarsals two through five as needed for correction of the deformity and parabola. We also discussed the possibility of an open Achilles lengthening with the patient. 2 diagnoses codes ICD 10 CM, 2 procedure CPT SCIENCE HEALTH SCIENCE NURSING HITM 1250

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