History and Physical and Labs

CC: Pain and swelling of plantar lateral aspect of left foot

HPI: LR is a 72 year-old women who reports exquisite tenderness and edema on the plantar lateral aspect of the left foot. This pain radiates up posterior to the left fibula.

PMH: LR is being treated for high cholesterol, hypertension, and hypothyroidism and generalized osteoarthritis. She was initially seen in this office on June 4, 2001 with a painful plantar aspect of her right heal. She was treated for bursitis and plantar fasciitis with a corticosteroid injection into the plantar fascia on the right foot and was prescribed physical therapy and had orthotic devices prescribed for her. X-rays revealed a moderately high arched foot , some localized osteoarthritis, large heel spurs present plantarly, and presents with a rather large os peroneum in the peroneal groove of the left cuboid (an os peroneum is a sesamoid bone that is commonly observed in some tendons of the foot, especially the peroneus longus tendon).

PSH: LR had a colectomy in 2000 and an appendectomy in 2000.

MEDS: Lipitor, Norvasc, Synthroid, Fosamax, Aleve, Inderal

Physical Exam:
VS: stable

HEENT: unremarkable

Cardiac: unremarkable

Lung: unremarkable

Abdomen: unremarkable

LOWER EXTREMITY:
Vascular
: Posterior tibial pulses and dorsalis pedis pulses intact and 2+/4 bilaterally.

Neuro: Her deep tendon reflexes and neuorlogic status is grossly intact.

Musculo/Skeletal: There appears to be a rather marked lateral instability in the left foot and marked edema along the peroneal tendon sheath as it courses along the lateral aspect to the calcaneus and cuboid. At rest her left foot is inverted, but her right foot is vertical.

Labs:
Unremarkable