Patient: [Patient Name]
Date: [Date of Encounter]
I. Reason for Visit:
Evaluation of a suspected or confirmed diabetic foot infection
II. History of Present Illness:
Duration of diabetes diagnosis
Current foot concerns (pain, redness, swelling, drainage, fever)
Location and description of any foot lesions
Duration of symptoms
Aggravating or relieving factors
History of previous foot ulcers or infections
Footwear use (proper fit, any recent changes)
III. Past Medical History:
Diabetes complications (neuropathy, peripheral arterial disease (PAD))
History of foot ulcers or infections
Other medical conditions affecting circulation (smoking, high blood pressure)
IV. Family History:
Diabetes or foot problems in first-degree relatives
V. Social History:
Smoking history (significant risk factor for PAD)
Occupation and daily activities (impact on feet)
Vision problems (can affect foot care)
VI. Physical Exam:
Vital signs (BP, HR, RR, Temp) – assess for fever and systemic inflammatory response
Foot inspection:
Skin integrity (breaks, redness, swelling, warmth, drainage)
Peripheral pulses (dorsalis pedis, posterior tibial) – assess for PAD
Sensation testing (monofilament) – assess for neuropathy
Ankle-brachial index (ABI) – may be done to assess PAD (consider referral for vascular studies if indicated)
Wound assessment (if present):
Size, depth, drainage characteristics (color, amount, odor), surrounding tissue involvement (cellulitis, abscess)
VII. Imaging Studies (consider as appropriate):
X-ray (to assess bone involvement in ulcers)
Ultrasound (to assess blood flow in PAD)
Bone scan or MRI (may be needed in some cases): To evaluate for deeper bone infection
VIII. Laboratory Studies:
White blood cell count (WBC): Elevated WBC may indicate infection.
Blood cultures (blood and wound cultures): To identify the infecting organism and guide antibiotic selection.
Inflammatory markers (CRP, ESR): May be elevated in infection.
IX. Assessment:
Diabetic foot infection (confirmed or suspected) based on clinical presentation and exam findings.
Severity of infection (mild, moderate, severe) – consider depth of tissue involvement, systemic inflammatory response, presence of gangrene.
Underlying diabetic neuropathy or PAD
Risk of limb ischemia or amputation
X. Plan:
Antibiotic therapy: Broad-spectrum antibiotics initiated promptly, intravenous route preferred for moderate/severe infections.
Narrow-spectrum antibiotics may be used after culture results are available.
Wound care: Aggressive debridement of necrotic tissue, appropriate dressings, infection control measures.
Offloading: Pressure relief techniques (wheelchair, special shoes) to promote healing and prevent further tissue breakdown.
Blood sugar control: Optimization of glycemic control is crucial for healing.
Pain management: Provide adequate pain relief to improve comfort and facilitate wound care.
Vascular consult (if indicated): For evaluation and management of PAD if present.
Possible surgical intervention (debridement, amputation): May be necessary in severe cases.
Hospitalization (for moderate/severe infections): Close monitoring and management in a hospital setting may be required.
XI. Prognosis:
Discuss the prognosis based on the severity of infection, response to treatment, and underlying vascular status.
Early diagnosis and treatment are essential to prevent complications like osteomyelitis, sepsis, and limb amputation.
XII. Notes:
Address the patient’s concerns and answer questions about the infection and treatment plan.
Provide emotional support and emphasize the importance of adhering to treatment recommendations.
Document education provided and patient understanding.
XIII. Resources:
Consider providing patient education materials on diabetic foot infections from reputable sources (e.g., American Diabetes Association (ADA), Infectious Diseases Society of America (IDSA)).