Patient Demographics
Name:
Age:
Sex:
Date of Birth:
Attending Physician:
Date of Note:
Reason for Encounter
Briefly state the reason for this encounter. This could be:
Initial evaluation for Achilles tendon pain.
Follow-up visit for a patient with known Achilles tendinopathy.
Evaluation of treatment response for Achilles tendinopathy.
History of Present Illness (HPI)
Onset and Duration:
When did the Achilles pain begin?
Has it been constant or intermittent?
Location and Character of Pain:
Where is the pain located (specific area of the Achilles tendon)?
Describe the pain (sharp, dull, aching)?
Aggravating and Alleviating Factors:
What activities worsen the pain?
Does anything improve the pain (rest, ice)?
Functional Limitations:
How has the pain affected your daily activities (walking, running, stairs)?
Past Medical History (PMHx):
Briefly mention any relevant past medical history, such as:
Previous injuries to the Achilles tendon
Inflammatory conditions (arthritis)
Systemic diseases (diabetes, gout)
Social History (SHx):
Include relevant social history that may be pertinent, such as:
Activity level (occupational or recreational)
Footwear habits
Medications
List all current medications the patient is taking.
Allergies
Document any known allergies, especially to medications used for pain management.
Physical Examination
Gait: Assess the patient’s walking pattern for any limping or altered gait mechanics.
Palpation:
Palpate the Achilles tendon for tenderness, swelling, or thickening.
Assess for point tenderness at specific locations (e.g., mid-substance, insertion).
Range of Motion:
Assess ankle dorsiflexion (bending the foot upwards) for limitations.
Tight calf muscles can contribute to Achilles tendinopathy.
Special Tests:
Perform specific tests like the Thompson test or Silfverskiold test to assess Achilles tendon integrity (may not be done in all cases).
Assessment
Summarize the key findings from the history and physical examination.
State the diagnosis of Achilles tendinopathy (acute or chronic based on presentation).
Plan
Outline the next steps in the patient’s management. This may include:
Non-surgical Treatment: (First line therapy for most cases)
Rest: Reduce or modify activities that aggravate the pain.
Ice: Apply ice packs to the affected area for 15-20 minutes at a time, several times a day.
Compression: Consider using a compression wrap to support the tendon.
Elevation: Elevate the ankle above the heart when resting.
Pain Management: Medications like NSAIDs (non-steroidal anti-inflammatory drugs) or acetaminophen may be used to manage pain and inflammation.
Physical Therapy: Stretching exercises to improve flexibility and strengthening exercises for the calf muscles are crucial for long-term management.
Orthotics: Custom orthotics may be helpful to improve foot biomechanics and reduce stress on the Achilles tendon.
Imaging Studies: (May be ordered depending on presentation)
X-ray (usually normal in tendinopathy, but can rule out fractures)
Ultrasound (can assess tendon thickness and identify tears)
MRI (most detailed view, may be used for complex cases)
Corticosteroid Injection: (Considered in some cases, but not a first-line treatment due to potential side effects)
Referral to a Sports Medicine Physician or Orthopedic Surgeon:
In severe cases, persistent pain despite conservative treatment, or suspected tendon rupture.
Prognosis
Briefly discuss the prognosis, which is generally good with early diagnosis and proper management.
Emphasize the importance of adherence to the treatment plan for optimal recovery and preventing recurrence.
Patient Education
Educate the patient about Achilles tendinopathy, the importance of rest and activity modification, proper stretching and strengthening exercises, and the expected course of treatment.
Discuss potential risks and benefits of treatment options.
Provide handouts or educational resources on Achilles tendinopathy management.
Additional Considerations
Adapt this template based on the specific situation (initial evaluation, follow-up visit).
Use