PODIATRY CONSULTATION RECORD State Form 53493 (R3 / 10-17) LOGANSPORT STATE HOSPITAL
PODIATRY CONSULTATION RECORD State Form 53493 (R3 / 10-17) LOGANSPORT STATE HOSPITAL
Unit MPI number
Name of patient Date of birth (month, day, year) Height Weight
Consulting Physician Date of appointment (month, day, year) Hour of appointment
Reason for request (See notice below and instructions on reverse side.) NIDDM IDDM Debridement of nail(s)
Attending LSH Physician Type of Consult / Referral Type of visit (check one)
Podiatry Initial Follow-Up Annual
Signature of attending Physician Date (month, day, year)
DIAGNOSES TREATMENTS
Abscess Foot / Toe Pressure Ulcer Calcaneal Spur Rest, Ice, Elevation X _____ days Plantar Wart / Verruca Clavus / Keratoma / Corn Blister Epsom salt soaks for ______mins. Bid X _____ days Vulgaris (hard) Contracted / Hammer / Cellulitis / Paronychia Wound / Contusion Bactroban Ointment apply bid X _____ days Mallet Toe Arthritis, Gouty / Osteo Candidiasis Hallux Limitus / Rigidus Sterile Dressing / Bandaid X _____ days
Achilles Bursitis Hyperhydrosis Hallux Valgus / Bunion Desoximethasone cream 0.25% apply bid X _____ days Metatarsalgia / Mycotic Nails / Heloma / Corn (soft) Ciclopirox cream 0.77% apply bid X _____ days Sesamoiditis Onychomycosis Plantar Fasciitis Tinea Pedis Immersion / Trench Foot Clortrimazole (Lotrimin) cream 1% apply bid X _____ days
Xerosis Morton’s Neuroma Econazole cream 1% apply bid X _____ days
Hypertrophic (Thickened) Nail(s) Pes Cavus / Flat Feet Lotrisone cream 1% / 0.5% apply bid X _____ days
______Pes Planus / High Arch Nystatin / Triamcinolone cream, apply bid X _____ days
______Sprain Tolnaftate 1% foot powder, sprinkle in shoes daily X _____ days
______Lamisil 250 mg, 1 daily X _____ days, liver profile now & in 3 weeks
Debridement of Nails Amoxicilin 500 mg, 1 every 8 hours X _____ days
Cephalexin (Keflex) 500 mg ______X _____ days
Cipro 1 every 12 hours X _____ days
Levaquin 500 mg, 1 every day X _____ days
Tylenol 325 mg ___ every ____ hours, prn pain, X _____ days
Carmol 20% bid X 28 days X 2 months
Salicylic Acid 17% bid X _____ days
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Return Appointment: Date (month, day, year): ______Time: ______at Logansport State Hospital or Office
Time Signature of Consultant AM Date (month, day, year) PM
ADDRESSOGRAPH NOTICE: Any charges for care rendered by your institution over $150 must be paid by the 590 Program, charges of $500 or more require prior approval, except for emergencies. Logansport State Hospital will file the application for this prior approval for you if you specify the services on the Consultation Record at the time of the initial and any subsequent consultations.