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(Quantity/Frequency)

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Achilles tendon reflexes*present / absentM If risk factors are present or an anomaly in the examination is noted, please conduct a full neurological ...

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? Department of Podiatry, LTU, 2003 AR & ARB 1

Presenting Complaint / Symptoms:

    ..................................................................................................................................................................................................................................................…….. .............................................................................................................................................................................................................…………................................ ..................................................................................................................................................................................................................................................…….. ? For past medical history please refer to the main file

    Diabetes History: Duration, type, current treatment, indicators of diabetes control (HBA1c, home blood glucose readings) ..................................................................................................................................................................................................................................................…….. .............................................................................................................................................................................................................…………................................ ........................................................................................................................................................................................................................................................... Diabetes related complications:

    Neuropathy ? Nephropathy ?Retinopathy ?Macro-vascular disease ? Detail................................................................................................................................................................................................................................................… Regularly sees a podiatrist: YES ???NO??

    Past history of foot problems: Ulceration including diagnosis, specific location and management ..................................................................................................................................................................................................................................................…….. .............................................................................................................................................................................................................…………................................ ..................................................................................................................................................................................................................................................……..

    Past history of foot surgery / amputation: Reason for procedure, level of amputation ..................................................................................................................................................................................................................................................…….. .............................................................................................................................................................................................................…………................................ Current ulceration? YES ???NO??

    If yes, list the initiating event, site, duration, signs and symptoms of inflammation / infection, previous treatment ..................................................................................................................................................................................................................................................…….. .............................................................................................................................................................................................................…………................................ ........................................................................................................................................................................................................................................................... Footwear / orthoses: Condition, type, fit, reason for mechanical therapy

    ..................................................................................................................................................................................................................................................…….. .............................................................................................................................................................................................................…………................................ ..................................................................................................................................................................................................................................................…….. Ability to self care: Vision, physical ability to perform, is assistance available?

    .................................................................................................................................................................................................................................................……..

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Symptoms:

     Tick

    Do your feet ever feel numb? ??

    Do your feet ever tingle as if electricity were travelling into your foot? ?

    ? Department of Podiatry, LTU, 2003 AR & ARB 2

    Do your feet ever feel as if insects were crawling on them? ?

    Do your feet ever burn? ?

     Other ? ...................................................................................................................................................................................................... Tests:

    Modality Right Foot Left Foot Explanation

     *sites not detected

    Monofilament (5.07) (out of 10 sites) /10 /10

     Apex of Apex of *present / absent Hallux Hallux Vibration Styloid Styloid Process Process (128Hz Tuning fork) Medial Medial MalleolusMalleolus

     *present / absent Achilles tendon reflexes

    If risk factors are present or an anomaly in the examination is noted, please conduct a full neurological assessment

    Risk factors / indicators for vascular disease:

     Tick Risk Factor Comments

    (Quantity/Frequency) ................................................................................... ......................................Smoking ??. Hypertension ? ..................................................... ............. .................................................................…………................ Diabetes ? (Type, history, recent BGL/HbA1C) ..............................……………….............................. .............… Hyperlipidaemia ? (Elevated LDL, low HDL)..............................................................................................…………………….... Hx relevant cardio/vasc ? pathology (eg. MCI, CVA) ...............................................................................................................………………... Advancing age ? .................................................................................................................................…………................ Slower healing rate ? (Previous ulceration, gangrene, amputations) ..........................................................................…. Past vascular surgery ? (Type) ....................……....................................................................................................………….... Sedentary lifestyle ? .................................................................................................................................…………................ Symptoms: intermittent ? .................................................................................................................................…………................claudication/rest pain Other? .................................................................................................................................…………................ Negative Risk Factors (eg. regular physical exercise, moderate alcohol) ..............................................…........................ ? ? Department of Podiatry, LTU, 2003 AR & ARB 3

Examination:

    L R Artery Remarks

     Dorsalis Pedis ...............................................................................................................

     Posterior Tibial ...........................................................................................................

     Perforating Peroneal ...........................................................................................................

     Popliteal ...........................................................................................................

     Femoral ........................................................................................................... Notation: NP = Not palpated; D = Diminished; N = Normal; B = Bounding

    If risk factors are present or an anomaly in the examination is noted, please conduct a full vascular assessment

Evidence of high pressure areas: Foot deformity (HAV, toe deformities, other), callus, footwear, cavus foot,

    other ..................................................................................................................................................................................................................................................…

    …..

    ..................................................................................................................................................................................................................................................……..

    Left Right Range of motion

     Ankle joint

     Subtalar joint Joint 1st MTPJ l

Summary of main gait observations:

    ..................................................................................................................................................................................................................................................…….. ..................................................................................................................................................................................................................................................…….. ....

    ..............................................................................................................................................................................................................................................……..

    If an anomaly in examination is noted please conduct a full biomechanical assessment, including Pedar? if indicated (seek assistance from supervisor)

    ? Department of Podiatry, LTU, 2003 AR & ARB 4

    List dermatological findings: skin and nail findings, current ulceration, hyperkeratosis, pressure areas, evidence of infection ..................................................................................................................................................................................................................................................…….. .............................................................................................................................................................................................................…………................................ ..................................................................................................................................................................................................................................................…….. ..................................................................................................................................................................................................................................................…….. .............................................................................................................................................................................................................…………................................

Risk factors for foot complications such as ulceration:

     Tick Risk Factor Tick Risk Factor

    Anomaly in neurological assessment ????Others

    Please list: (Male gender, advancing age, long diabetes duration, Evidence of abnormal pressure ? poor BGL control, lower socio-economic status, lack of support networks, (intrinsic or extrinsic) living alone) Past history of foot ulceration / ? amputation ......................................................................................................................................

    ......................................................................................................................................Macrovascular pathology ...................................................................................................................................... ? (implicated in reduced healing)

    LOW Category 0: No pathology

     Category 1: Neuropathy, no deformity Category 2: Neuropathy with deformity MODERATE

    Category 3: History of pathology

     Category 4A: Neuropathic wound

     Category 4B: Acute Charcot’s joint HIGH

    Category 5: The infected diabetic foot

    Category 6: The ischaemic limb

    (Refer to the University of Texas Diabetic Foot Classification System for full details)

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     ? Department of Podiatry, LTU, 2003 AR & ARB 5

1. Podiatric treatment/further assessment: Including short and long term treatment & goals

    ............................................................................................………......................................................................................………..........................……………………… ............................................................................................………...................................................................................................…….………...............……………… ............................................................................................………...................................................................................................................…………………….……... ............................................................................................………......................................................................................................………......……….........……….…. ............................................................................................………............................................................................................…......................………………….……... ............................................................................................………......................................................................................................………...............………………….. ............................................................................................………...................................................................................................................…………………………… ............................................................................................………......................................................................................................………......……….........……….…. ............................................................................................………............................................................................................…......................………………….……... ............................................................................................………......................................................................................................………...............………………….. 2. External Referrals:

??GP ??Endocrinologist

    ??Specialist High Risk Foot / Ulcer Clinic ??Dietician

    ??Diabetes educator ??Psychologist / Social worker ??Other: ??Further tests indicated:

    List: ……………………………………………………………………………………… List: …………………………………………………………………………………… ……………………………………………………………………………………………… ……………………………………………………………………………………………… ……………………………………………………………………………………………… ……………………………………………………………………………………………… 3. Footwear: ...........................................................................................................................................................……..............................………................ .......................................................................................………......................................................................................……..............................……………………........

     ............................................................................................………......................................................................................................………......……….........……….…

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    4. Pressure reduction therapy: padding, orthoses, silicone device, other................………..........................…………………………………...

    ...........................................................................................………......................................................................................................………......……….........……….…..

    ...........................................................................................………......................................................................................................………......……….........……….…. 5. Education: verbal and written education and referral to other support

    services ...............................................…….....….....................................................................................................................……….............…………………………

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     ...........................................................................................………......................................................................................................………......……….........……….…. 6. A diabetes foot re-assessment is recommended in:

     1 month ? 3 months ? 6 months ? 12 months ? Other ......................................…

    ? Department of Podiatry, LTU, 2003 AR & ARB 6

Student signature: ………………………………………………………………………………………………………….

    Clinician signature: .................................................…...............................................…...................………. Date: ......................................……...........

? Department of Podiatry, LTU, 2003 AR & ARB

    ? Department of Podiatry, LTU, 2003 AR & ARB 7

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