Patient: [Patient Name]
Date: [Date of Encounter]
I. Reason for Visit:
Routine diabetic foot exam
Evaluation of a new foot concern (wound, ulceration, pain, deformity)
Follow-up visit for a diabetic foot problem
II. History of Present Illness:
Duration of diabetes diagnosis
Current foot concerns (pain, numbness, tingling, burning, wounds, discoloration)
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)
Foot inspection:
Skin integrity (breaks, calluses, discoloration)
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, surrounding tissue involvement (infection signs)
VII. Imaging Studies (consider as appropriate):
X-ray (to assess bone involvement in ulcers)
Ultrasound (to assess blood flow in PAD)
VIII. Assessment:
Diabetic foot risk status (based on history, exam findings) – high risk, moderate risk, low risk
Presence of diabetic neuropathy or PAD
Presence of a diabetic foot ulcer or other foot problem
Risk of infection
IX. Plan:
Management plan may include:
Education: Importance of daily foot self-care (inspection, washing, drying), proper footwear selection, healthy lifestyle choices (smoking cessation).
Offloading: Pressure relief techniques (wheelchair, special shoes) for existing ulcers to promote healing.
Wound care: Debridement, dressings, infection control measures (if applicable).
Referral to a podiatrist or wound care specialist: For treatment of complex wounds or offloading recommendations.
Management of underlying conditions: Blood sugar control, blood pressure control, smoking cessation to reduce risk of complications.
Appropriate footwear: Properly fitting shoes with good cushioning and depth to accommodate any deformities.
X. Prognosis:
Discuss the importance of ongoing foot care to prevent ulcers and infections.
Early detection and treatment of foot problems can prevent amputations.
XI. Notes:
Address the patient’s concerns and answer questions about foot care.
Provide emotional support and emphasize the importance of self-care behaviors.
Document education provided and patient understanding.
XII. Resources:
Consider providing patient education materials on diabetic foot care from reputable sources (e.g., American Diabetes Association (ADA), American Podiatric Medical Association (APMA)).