Welcome to the Podiatry Arena forums, for communication between foot health professionals about podiatry and related topics.
You are currently viewing our podiatry forum as a guest which gives you limited access to view all podiatry discussions and access our other features. By joining our free global community of Podiatrists and other interested foot health care professionals you will have access to post podiatry topics (answer and ask questions), communicate privately with other members (PM), upload content, view attachments, receive a weekly email update of new discussions, earn CPD points and access many other special features. Registered users do not get displayed the advertisments in posted messages. Registration is fast, simple and absolutely free so please, join our global Podiatry community today!
If you have any problems with the registration process or your account login, please contact contact us.
One of the common problems for those seeking clinical advice for their patients here on Podiatry Arena is that, within their postings, there is inadequate clinical information presented and/or their presentation is in such an unorganized manner that is makes it difficult, if not impossible, for us to help. This lack of clinical information creates frustration to those of us who actually want to take the time out of our busy day to offer advice and help. Therefore, the practitioner that does not ask their question with sufficient information or with sufficient clarity is much less likely to get the answer they need, whereas the practitioner that does ask their question in an organized manner with good clarity and detail is much more likely to get a useful answer to their questions.
When I was in my podiatry school and residency training, I was grilled endlessly, sometimes to the point of embarrassment, by my instructors to present patients to them with a standard medical presentation organization. This was done for one reason....to make me a better clinician with a more organized thought process. These items of organization that were grilled into me, over and over again, included the following:
Chief Complaint (CC)
History of Present Illness (HPI)
Past Medical History (PMH)
Physical Exam (PE)
Diagnostic Tests
Differential Diagnosis
Treatment Plan
Is not this same manner of presenting a patient's case to other clinicians not taught in other countries? This manner of presenting a patient to a clinician is standardly taught in podiatry schools here in the US.
Here is a hypothetical typical example of a patient presented here on Podiatry Arena:
Quote:
Originally Posted by Joe the Pod
I just recently saw a 46 y/o male with a 5 degree rearfoot varus and a 3 degree forefoot valgus with a massive equinus and forefoot pain. I have tried an over-the-counter orthosis but he hasn't gotten any better, even though I have sent him to physiotherapy. He walks with a limp more on the right foot and has Type 2 Diabetes, but doesn't have any neuropathy. The physiotherapist could only find a 1/3 dorsalis pedis and posterior tibial pulse so we think he has a vascular condition and now think that his pain must be vascular in origin. Can somebody please help since I don't know what to do from here??
Here is the way that this patient should be presented to a clinician in the clinic, in the hospital or on Podiatry Arena:
Quote:
Originally Posted by Pod Supreme
CC: A 46 y/o white male with a history month history of intermittent, aching pain plantar to bilateral metatarsal heads.
HPI: Forefoot pain is made worse by weightbearing activities, and made better with non-weightbearing activities. Different styles of shoes have no effect on pain but pain is worse while barefoot walking. Treatment with over-the-counter orthoses have been of little relief. Two weeks of physiotherapy including deep tissue massage and ultrasound have been of little relief.
PMH: Three year history of type 2 Diabetes with no sequelae and no peripheral neuropathy. Otherwise unremarkable.
PE:
Musculoskeletal: Patient has a mild metatarsus adductus, a mild pes cavus deformity and only 0 degrees of ankle joint dorsiflexion with the knee extended and 7 degrees of ankle joint dorsiflexion with the knee flexed bilaterally. Rearfoot varus of 5 degrees, forefoot valgus of 3 degrees bilaterally. STJ axis is mildly medially deviated bilaterally in relaxed bipedal stance. Area of maximum tenderness is at the 2nd and 3rd MPJs, specifically at the insertion of the plantar plate into the base of the proximal phalanx of the 2nd and 3rd digits. Slight palpable plantar edema is noted, negative vertical drawer test at the digits, no pain with MPJ dorsiflexion but moderate pain with full MPJ plantarflexion range of motion of MPJ. Otherwise, musculoskeletal exam is within normal limits (WNL).
Gait examination: Slight pronation in contact phase, slight early and late midstance pronation, a moderately early heel off, and a moderately apropulsive gait pattern on the right and mildly apropulsive gait pattern on the left with an antalgic gait, favoring propulsion more on the right foot than the left.
Neurological: WNL Dermatological:WNL Vascular: DP is 1/3 and PT is 1/3 bilaterally. Sub papillary venous plexus filling time (SPVPFT) is 4 second bilaterally at the hallux.
Tests: None available.
Diagnosis:
1. Right greater than left 2nd and 3rd MPJ capsulitis (probable early plantar plate tear)
2. Bilateral gastrocnemius and soleus equinus deformities
3. Type 2 Diabetes mellitus
Treatment Plan:
1. Three times a day gastrocnemius and soleus stretching exercises.
2. 20 minutes twice a day icing therapy.
3. Avoid barefoot walking, wear OTC orthoses. Add anterior edge pads of 5 mm adhesive felt to anterior edges of OTC orthoses and give advice on appropriate shoegear.
4. Return to clinic in 3 weeks and discuss custom foot orthoses if not making significant improvement in 3-6 weeks.
5. Appropriate diabetic foot care protocol advised.
Hopefully those who want to ask clinical advice in the future here on Podiatry Arena could be more specific and thorough in their presentations. In this fashion, we will not only be able to help your patients more, but also be able to help you in becoming better clinicians.
__________________
Sincerely,
Kevin
**************************************************
Kevin A. Kirby, DPM
Adjunct Associate Professor
Department of Applied Biomechanics
California School of Podiatric Medicine at Samuel Merritt College
I have this printed at the bottom of every patient notes sheet to remind myself and all our podiatrists of the logical order of writing notes and presenting patients. PC GOAL HX FOOTWEAR OBS PALP GAIT DDX RX PLAN PROGNOSIS
Nature - Location - Onset - Duration - Confounding - Aggravating - Treatment - Special
PC stands for presenting complaint which is the same as (CC)
I also like to get an initial idea of what the patients perception and expectations of the goals of their treatment will be ie. resolution or reduction of symptoms/problems.
I place a lot of emphasis on history and the second line is the key factors for taking a patient history. The Special bit includes past medical history and familial history. NLODCATS
I have an extra section on Footwear that includes a history and a physical exam of worn athletic and casual shoes.
Before touching the patient I do a full body postural exam that includes a functional component. This then segues into the static exam of joint ROM. I like to follow a top down method of examining the joints. (OBS) is as in observation.
I will either do palpation or a gait analysis next. The palpation includes clinical diagnostic tests as well as an attempt to illicit the pain/symptoms. We do a barefoot gait analysis walking and running on a treadmill followed by a quick exam running outside in their shoes at their normal pace and a faster pace.
After this is the Differential Diagnosis that must include the possible causes and contributing factors and not just a name for the injury.
From there it is relatively simple to create a Treatment Plan that includes a treatment pyramid from Short Term to Long Term and interventions for symptomatic relief and to deal with each of the causative factors.
At the end of each initial appointment I try to present the case to each patient going through DDx, the treatment Plan and the likely prognosis so that they are aware of what I think should be done and why it should be done and the likelihood of success. I think it is also good to empower the patient to make the decision on the desired course of action after educating them on their condition.
Presenting every patient you see back to them gives you the experience to follow a concise logical plan to present patients to other podiatrists and other practitioners. While it may not always happen that you follow the same plan in the same order for every patient I think routines improve success rates.
__________________
********************************
Steve Manning
Director - Runner - Podiatrist Intraining Running Centre Intraining Running Injury Clinic
33 Park Road Milton Qld 4064 AUSTRALIA
07. 3367 3088 www.intraining.com.au
footman@intraining.com.au
The Following User Says Thank You to Steve The Footman For This Useful Post:
I have this printed at the bottom of every patient notes sheet to remind myself and all our podiatrists of the logical order of writing notes and presenting patients. PC GOAL HX FOOTWEAR OBS PALP GAIT DDX RX PLAN PROGNOSIS
Nature - Location - Onset - Duration - Confounding - Aggravating - Treatment - Special
PC stands for presenting complaint which is the same as (CC)
I also like to get an initial idea of what the patients perception and expectations of the goals of their treatment will be ie. resolution or reduction of symptoms/problems.
I place a lot of emphasis on history and the second line is the key factors for taking a patient history. The Special bit includes past medical history and familial history. NLODCATS
I have an extra section on Footwear that includes a history and a physical exam of worn athletic and casual shoes.
Before touching the patient I do a full body postural exam that includes a functional component. This then segues into the static exam of joint ROM. I like to follow a top down method of examining the joints. (OBS) is as in observation.
I will either do palpation or a gait analysis next. The palpation includes clinical diagnostic tests as well as an attempt to illicit the pain/symptoms. We do a barefoot gait analysis walking and running on a treadmill followed by a quick exam running outside in their shoes at their normal pace and a faster pace.
After this is the Differential Diagnosis that must include the possible causes and contributing factors and not just a name for the injury.
From there it is relatively simple to create a Treatment Plan that includes a treatment pyramid from Short Term to Long Term and interventions for symptomatic relief and to deal with each of the causative factors.
At the end of each initial appointment I try to present the case to each patient going through DDx, the treatment Plan and the likely prognosis so that they are aware of what I think should be done and why it should be done and the likelihood of success. I think it is also good to empower the patient to make the decision on the desired course of action after educating them on their condition.
Presenting every patient you see back to them gives you the experience to follow a concise logical plan to present patients to other podiatrists and other practitioners. While it may not always happen that you follow the same plan in the same order for every patient I think routines improve success rates.
Steve:
This is excellent and a thorough way to evaulate patients. However, don't you also agree that many of the clinicians presenting patients here on Podiatry Arena give too little information or with too little precision to have you help them with their patients?
__________________
Sincerely,
Kevin
**************************************************
Kevin A. Kirby, DPM
Adjunct Associate Professor
Department of Applied Biomechanics
California School of Podiatric Medicine at Samuel Merritt College
This is excellent and a thorough way to evaulate patients. However, don't you also agree that many of the clinicians presenting patients here on Podiatry Arena give too little information or with too little precision to have you help them with their patients?
Yes I do agree that trying to make a constructive comment can be difficult with incomplete information. I think it is also a question of following a logical pattern to presentation - so that is where having a template or format as you suggested makes it easier to present complete information and not miss significant points. I think it can be reflective of having poor routines in the assessment that miss relevant factors in the condition. While difficult patients will present that do not follow normal symptoms, most patients can be accurately diagnosed and treated if you get the right information.
__________________
********************************
Steve Manning
Director - Runner - Podiatrist Intraining Running Centre Intraining Running Injury Clinic
33 Park Road Milton Qld 4064 AUSTRALIA
07. 3367 3088 www.intraining.com.au
footman@intraining.com.au
I totally agree. However I think more than not it is because some of those questions haven't been asked/documented/considered.
This discussion came up a few weeks ago with some pod's in regarding to paed's and how much of a birth history do you take and how far do you go back.
I don't understand why you don't ask as many things as relevant and possible as you can. It is called thorough history taking for a reason. It assists you to then know what you need clinically examine in detail.
Systematic history and exam promotes good clinical differential diagnosis.
__________________
Cheers,
Cylie.... in a permanent state of confusion
regarding to paed's and how much of a birth history do you take and how far do you go back.
As I repeatedly say to the students (and not just in the context of paediatics), you ask what is relevant and you do not ask what is not relevant and you always make sure they understand why you need to ask those questions.
You do not need the birth history in all paeds patients (ie a VP is an obvious one); you do need it in a delayed walker ...BUT, I also extoll the students to make sure the parents understand the need for the questions. Put yourself in the parents place .... they come in with a kid with a "flatfoot" and you start asking about brith history!! - they need to know why you need that information (if its relevant).
__________________ Craig Payne
__________________________________________________ ___________________________________ Follow me on Twitter | Run Junkie God put me on this earth to accomplish a certain number of things - right now I am so far behind, I will never die.
The Following User Says Thank You to Craig Payne For This Useful Post:
Problem is when you are still 5-10 years out and still wondering why you should ask if there was any complications at birth for a 5 year old that can never get their heels to the ground, one starts to scratch the head and wonder what they are missing out of their history taking when asking for heel pain or sports injury etc.
I'm still not sure everyone has got a good understanding of clinical relevance in history taking, ie: How many times is a standard assessment form used in practice, therefore struggles to present something as factually as the outline. It is great to have that written prompt for people to consider.
__________________
Cheers,
Cylie.... in a permanent state of confusion
Chief Complaint (CC)
History of Present Illness (HPI)
Past Medical History (PMH)
Physical Exam (PE)
Diagnostic Tests
Differential Diagnosis
Treatment Plan
Hi Kevin,
I have tried to refine your suggested organisation of presenting cases for use at the new QUT University Podiatric Sports Medicine Clinic. I wanted something that I could give to the students that would give them a framework to present their cases with an orthopaedic perspective.
One key factor is the limited amount of time that the students have to present. While they have 90 minutes for each patient that includes the time that the 8 students have to present their cases to me. I figure if I have 5 minutes for each student then they all have at least 50 minutes to do what is necessary before presenting their case. This should be enough for a fourth year student.
It is fairly similar with the edition of their sport first up, a specific section on palpation and an itemised treatment plan.
Any thoughts of the workability of that?
WHAT TO PRESENT:
1. Patient Name and activity/sport
2. Presenting complaint (CC)
3. Significant History (HPI/PMH/Footwear)
4. Significant Findings of Postural/Static/Gait exams (PE)
5. Palpation
6. Special Exams and Diagnostic Tests
6. Differential Diagnosis with Causes of Injury (DDx)
7. Treatment Plan including:
- Symptomatic Rx
- Treatment of causes of injury
- Goal and Prognosis and further Rx/Tests
__________________
********************************
Steve Manning
Director - Runner - Podiatrist Intraining Running Centre Intraining Running Injury Clinic
33 Park Road Milton Qld 4064 AUSTRALIA
07. 3367 3088 www.intraining.com.au
footman@intraining.com.au
The only thing I would add to that, and is something I try to hammer into the students ... is I also want to know what impact the presenting complaint is having on them (eg is it interfering with sport participation or employment) ... as the immediate management may be different if they can't run or can't stand at work vs a minor irritant during running or not affecting their ability to work.
__________________ Craig Payne
__________________________________________________ ___________________________________ Follow me on Twitter | Run Junkie God put me on this earth to accomplish a certain number of things - right now I am so far behind, I will never die.
The Following User Says Thank You to Craig Payne For This Useful Post:
The only thing I would add to that, and is something I try to hammer into the students ... is I also want to know what impact the presenting complaint is having on them (eg is it interfering with sport participation or employment) ... as the immediate management may be different if they can't run or can't stand at work vs a minor irritant during running or not affecting their ability to work.
That is certainly the key to the "nature" of the injury. It has an affect on how they are dealing with being injured and their perceived goals or expectations of visiting a podiatrist. That is also why I think the prognosis is so important to communicate to the patient.
__________________
********************************
Steve Manning
Director - Runner - Podiatrist Intraining Running Centre Intraining Running Injury Clinic
33 Park Road Milton Qld 4064 AUSTRALIA
07. 3367 3088 www.intraining.com.au
footman@intraining.com.au
I am in agreement, where case discussions are concerned. Also, in a training program- it is necessary. But do you really have enough time for extensive history-taking in practice? I do my best, and I'm told it's better than most, but we are just too busy. The computer-based record keeping and documentation system helps, with templates and drop-downs, but it is not practical. Comments?? -John
__________________
Dr. John G. Fasick II
Clinical Insructor, LSU School of Medicine
Advanced Foot & Ankle Center of East Jefferson footankledoc2@gmail.com
I am in agreement, where case discussions are concerned. Also, in a training program- it is necessary. But do you really have enough time for extensive history-taking in practice? I do my best, and I'm told it's better than most, but we are just too busy. The computer-based record keeping and documentation system helps, with templates and drop-downs, but it is not practical. Comments?? -John
Time pressures will impact on patient care. However I think if you have an organised structure in your history taking then it will ultimately take less time. With each patient the information you collect and questions you ask will be directed by what has come before. The risk is that you may miss something of significance. A structured history will reduce that risk somewhat. It would be impossible to ask your patient every possible question and even your patient would start to wonder about the relevance.
The allocation of time you give to an initial patient will certainly have an affect on your patient history. We give 45 minutes to initials and just charge more than the going rate. That gives us 20 to 30 minutes for a thorough history. I would rather spend more time in the beginning and get the diagnosis and treatment plan right then waste time later because I was not able to identify significant information.
Perhaps I am just not pushing myself out of my comfort zone. I could conceivably do everything that was needed in 30 minutes but I would be much more stressed out. It is difficult to comment on someone elses situation because we all need to work around meeting the needs of our communities and our businesses.
__________________
********************************
Steve Manning
Director - Runner - Podiatrist Intraining Running Centre Intraining Running Injury Clinic
33 Park Road Milton Qld 4064 AUSTRALIA
07. 3367 3088 www.intraining.com.au
footman@intraining.com.au
Hi I explain to clients that without the extensive history we may miss something and long term make it harder to treat their particular symptoms.
The more questions you ask the more detail you get, as they often come up with things that they had forgotten then is the perfect time to state again the reason for the detailed history.
I find they nearly always come up with a "pearler" long after they think they have told you everything.
Cheers
__________________
Heather J Bassett
137 Wheatsheaf Road
GLENROY VICTORIA 3046
AUSTRALIA
03 9306 8557
I explain to clients that without the extensive history we may miss something and long term make it harder to treat their particular symptoms.
The more questions you ask the more detail you get, as they often come up with things that they had forgotten then is the perfect time to state again the reason for the detailed history.
I find they nearly always come up with a "pearler" long after they think they have told you everything.
Exactly. One of the reasons we developed that HUGE Paed assessment form that I know you love so much, Heather (tongue firmly planted in cheek!)
__________________
Cheers,
Cylie.... in a permanent state of confusion
I am in agreement, where case discussions are concerned. Also, in a training program- it is necessary. But do you really have enough time for extensive history-taking in practice? I do my best, and I'm told it's better than most, but we are just too busy. The computer-based record keeping and documentation system helps, with templates and drop-downs, but it is not practical. Comments?? -John
I know this post is old, however today I had the best new pt dental apt I've ever been to. He had an assistant there to record his measurements as he went and dictated his findings as he examined. Some of us fail to recognize an Investment in manpower can pay off in the long run. I spend a lot of time charting mgmt plans/ assess findings and would love to do dictation instead. Once I have more pts, this is a model I will adopt.
I have another apt in a week to review his findings and go over the mgmt plan. Some pods do this, probably not enough though. I typically go over mgmt plan first visit, but it can be overwhelming for the pt.
I have another apt in a week to review his findings and go over the mgmt plan. Some pods do this, probably not enough though. I typically go over mgmt plan first visit, but it can be overwhelming for the pt.
Sarah
So, you're going back next week to pay for another appointment when he'll actually tell you what he plans to do? WOW, nice work if you can get it. So when you've paid for your next appointment in which he tells you what he plans to do, I presume you'll then be paying for yet another appointment when he actually does something?
I don't know how you do things on your planet but on mine it's like this....... Plymouth, UK. If I tried to run my business like the above, I wouldn't have one. I know: let's devise an appointment system with the aim of ripping people off..... nice, sleep well. Can I suggest you allow more time to allow you to do what you need to do in one appointment and charge accordingly in the first place. One appointment per week with an injured individual is not great if it takes 3 weeks before you actually start to treat.
So, you're going back next week to pay for another appointment when he'll actually tell you what he plans to do? WOW, nice work if you can get it. So when you've paid for your next appointment in which he tells you what he plans to do, I presume you'll then be paying for yet another appointment when he actually does something?
I don't know how you do things on your planet but on mine it's like this....... Plymouth, UK. If I tried to run my business like the above, I wouldn't have one. I know: let's devise an appointment system with the aim of ripping people off..... nice, sleep well. Can I suggest you allow more time to allow you to do what you need to do in one appointment and charge accordingly in the first place. One appointment per week with an injured individual is not great if it takes 3 weeks before you actually start to treat.
Can I say you're coming off as a bit of an ass?
Today I paid for assessment, x-rays and a cleaning. He wants time to go over the x-rays in detail before presenting the management plan. Next visit is a free consult to review my situation, basically part of what I paid for today. Then I will pay for what ever treatments I decide to consent to. Do you tell your surgery patients exactly what procedure you will do after simply glancing at their foot and x-rays during their first sit-down in your office?
Too many of us just manage day to day without a good plan in place. Or we have a great plan but never disclose it to the patient. Never mind the ones who can't diagnose their way out of a paper bag and just throw modalities at problems hoping for success. If you can give the plan based on the first assessment and don't have to analyze x-rays, wait for confirmation test results, you should do it.
But if your patient doesn't know where you are going wih mgmt early on, orthotics and proposed surgeries appear to be a cash grab or last resort since everythig else is failing (aka you are failing) instead of being essential components of your long term plan to prevent reocurrance once injury has healed.
Perhaps you don't realize how badly some pods, doctors, dentists, massage therapists, physios are practicing out there. Can't see the forest for the trees. Can't see the big picture, don't address the etiology.
In my world, my advice doesn't come free. No free assessments at my clinic. And phone consults are general in nature, you need to come in to be assessed for me to give you advice specific to your situation, and I have the receptionist let them know there is a fee for these so they truck hour feet in and sit in my chair. Why should his advice come free?
Sure. Can I just say that in your last post you came over as a bit of a money grabbing...? And in the one above your grasp of economics seems skewed and yet again, you come across as a money grabber. Let's just agree to disagree. Goodnight, Sarah. "Don't cast judgement upon others, or you might get judged too"- The life of Brian, Monty Python.
Well said:
"But if your patient doesn't know where you are going wih mgmt early on, orthotics and proposed surgeries appear to be a cash grab or last resort since everythig else is failing (aka you are failing) instead of being essential components of your long term plan to prevent reocurrance once injury has healed.
Perhaps you don't realize how badly some pods, doctors, dentists, massage therapists, physios are practicing out there. Can't see the forest for the trees. Can't see the big picture, don't address the etiology."
I prefer to have a longer amount of time initially for extensive history taking without the pressure.
This means you can get a well rounded detailed history and perform a thorough examination as well as discuss issues, prognosis, goals and management plans without feeling like you are under the pump and risking missing something crucial.
This then saves you time (as a general rule) on follow ups because you have come to a better differential diagnosis and produced a better management plan, so there is less to 're-cover' at subsequent appointments.
I also find that if things aren't progressing as expected you have a better body of information to cross refernce and further study in between appointments (or for presenting here on pod arena)
Hello all
thanks for this info we have a lot of students coming through and I have a team of Pods who I give second opinions to and when they present their patients I also find that there is a lack of info provided - maybe stuff that you would assume they would ask and then realise maybe you shouldn't assume anything. I am currently trying to standardise our assessment forms for bio patients both adults and paeds I would appreciate any copies that people could post up so I can get a few ideas. cheers
Agreed. Trying to figure out some of these cases is like trying to diagnose on a partial or improperly performed examination. I find it difficult to learn from the discussions as a result, as most of the treads involve many requests for additional information and become disorganized.
It's similar to the problems I have had with my sudents in clinic. I had to send one back into the room to perform the neurological elements he missed on his "completely normal" stroke patient. After being offended by the fact that I told him his examination was incomplete, he later was grateful and thought the positive babinsky was cool, he'd never seen one before.
Most I interact with cannot yet use the history questions to direct an examination, so therefore cannot yet see the value of the questions they are asking. Most students drop too many routine examinations too early on in the game, justifying their exclusion with superficial reasons "just nail care", "not enough time", and thus don't get enough experience with them. We develop bad habits early, and keep them up through practice. If you don't have a thorough in-depth knowledge of how common conditions present and are initiated, it is difficult to interperet history questions.
Some people jump to the examination stage too early and get side-tracked, playing guessing games with their shot-gun approach to adjunctive testing requests and examinations, all the while missing important information on pain patterns, exacerbating factors, limitations on activity etc that can clinch a diagnosis.
The use of a template would be beneficial.
Please include comments. So that the presenter can explain why they are asking for help.
Please include discussion. So the readers can understand the problems the practitioner has working on the case.
And I personally would like to see a thank you section to thank those who have dedicated their lives to be a good doctor.
BTW thanks Kevin, your writings have helped me greatly and therefore those that I have seen.
The use of a template would be beneficial.
Please include comments. So that the presenter can explain why they are asking for help.
Please include discussion. So the readers can understand the problems the practitioner has working on the case.
And I personally would like to see a thank you section to thank those who have dedicated their lives to be a good doctor.
BTW thanks Kevin, your writings have helped me greatly and therefore those that I have seen.
Joe:
Welcome to Podiatry Arena. One of the common problems that we have here on Podiatry Arena is that many of the podiatrists/clinicians asking for patient advice don't include a lot of information on their patients that they are asking for advice on. Therefore, it becomes difficult to give them any worthwhile suggestions. This is why I started this thread....to plead for better initial patient information so that we can help out their patients more efficiently and thoroughly.
Also, you can thank an author of a post by just clicking on the "Thanks" box in the bottom right of every post.
Hope all is well....long live the Motley Crew!
__________________
Sincerely,
Kevin
**************************************************
Kevin A. Kirby, DPM
Adjunct Associate Professor
Department of Applied Biomechanics
California School of Podiatric Medicine at Samuel Merritt College
Presenting Patients for Clinical Advice
(tongue firmly planted in cheek!)
Hybrid Mode
