Office Note Sample:

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RE:   Debra Jones
DATE 12/01/10
MR:  240804
DOB: 12/01/65


She returns today for follow-up of low back pain and a new problem with her right foot and ankle.  Concerning her low back pain, she still has it.  It radiates to her left leg.  She tells me that she is scheduled to see her PCP next week. She has intermittent pain pointing to the area of the talonavicular joint of her right foot.  She has had polio.  She has had a triple arthrodesis 40 years ago.  She is having intermittent pain about five times over the last month.  It is difficult to walk when she gets it

Examination demonstrates tenderness over the talonavicular joint.


Plain x-rays show the subtalar and calcaneonavicular joint solidly fused as some joint space that is visible of the talonavicular joint has a cyst in the neck of the talus.


We will get an open MRI to further evaluate this area in fine detail.  We will ask her to wear a cam walker for pain relief with ambulation.

We will see her back in four weeks.