Case Problem 10: Task: Perform a focused history and expanded physical examination.

Mr. Robbins is a 39 year old man who presents to clinic complaining of dry skin and sore
callouses that have been worsening over several years. He reports that in the summer his feet
itch and he gets jock itch. He has tried Lotrimin-AF cream and Goldbond powder. He wants
to get rid of these foot problems.

Vitals: BP right arm 100/89, Height 60, Weight 185 lbs, He rates the callous pain 5/10 (VAS)
when weight bearing.
Medications: The patient is currently not taking any medications
Allergies: He denies neither medication nor food allergies.
PMH: He denies significant past medical history. He specifically denies hepatitis, cirrhosis and
liver problems.
PFH: His father has always had bad toenails and callouses. His mother is deceased after
suffering complication of her diabetes.
PSH: He works 40 hours per week as an auto mechanic. He smokes one half of a pack of
cigarettes each day since high school. He admits to drinking 2-3 beers on the weekend.
ROS: Patient denies any other system symptoms.
Additional question(s) you might have for your patient:

On the back of this page, all the appropriate physical examination steps that you would do in
the order you would perform them:

Dermatological description of the right sole:

Dermatologic description of left sole:

Your Differential Diagnoses (3 or 4 per problem):

Problem A:

Problem B:

Interpret this plantar skin scraping:

Assessment:
In a complete sentence for each problem, link the pertinent elements of the history and
physical to your diagnosis and prognosis:
Problem A:

Problem B:

Management Plans:
1. Imaging / Tests / Orders:

2. Write the exact words you would use to effectively communicate your diagnoses and
treatment plans. Use terms the patient can understand. Finish on the back of this page:

3. Write an appropriate, complete and specific prescription (Rx, Dsp, Sig):

4. Write the exact words you would use to effectively communicate to your patient how to
apply and or use your prescription(s):

4. In patients terms, write a prevention plan:

5. Respond in patients terms to the patients question: Is this contagious?

6. Billing and Coding: What are you going to bill for?

Service Description:

Current
Procedures
Terminology
codes

Diagnosis
Codes:

Your
Charges:

Online Resources:
A. Medical Content: KSUCPM student subscription: UpToDate website:
http://www.uptodate.com/home
B. Procedure and Diagnosis Coding: Family Practice Super Bill
http://www.aafp.org/journals/fpm/explore/topic/icd-9.html#superbill
C. Approved Payment Information: Centers for Medicare and Medicare Services
https://www.cms.gov/apps/physician-fee-schedule/overview.aspx

Facilitator: Myron Bodman DPM, Associate Professor KSU CPM

Contact me with any questions at mbodman1@kent.edu

Estimated
Approved
Payments: