Initial Podiatry Assessment – Outpatient
Reason for Referral:
Referral from community clinic for routine diabetic foot screening due to a history of type 2 diabetes mellitus and recent reports of numbness in both feet.
Presenting Foot/Lower Limb Concerns:
Patient reports bilateral foot numbness, particularly in the toes, for the past 6 months. Occasional sharp, shooting pain in the left great toe. Denies any open wounds or significant discomfort with current footwear. Expresses concern about potential complications given his diabetes.
Medical and Surgical History:
Diagnosed with Type 2 Diabetes Mellitus 10 years ago, currently managed with oral hypoglycaemics (Metformin). History of hypertension, controlled with Lisinopril. No previous foot ulcers, amputations, or lower limb surgeries. Patient had a cataract removal 2 years ago.
Functional Status and Mobility:
Patient reports being able to walk approximately 2 miles daily for exercise without significant discomfort. Uses no assistive devices. Maintains good balance. Can easily access clinics via public transport and does not require home support.
Footwear and Orthoses:
Patient primarily wears 'takkies' (athletic shoes) which are well-fitting and in good condition. Occasionally wears formal shoes for special occasions. Does not use any orthotics, either state-provided or private.
Podiatric Examination:
**Foot Posture:** Pes planus bilaterally with mild hallux valgus left foot.
**Skin Condition:** Mild dryness on heels, no fissures or callus. Intact skin integrity throughout.
**Nail Health:** Clear, well-trimmed nails. No signs of fungal infection.
**Signs of Infection:** No redness, warmth, or swelling observed.
**Pulses:** Dorsalis pedis and posterior tibial pulses palpable bilaterally (2+/4).
**Capillary Refill:** <3 seconds bilaterally.
**Temperature:** Normal and symmetrical.
**Monofilament Sensation:** Loss of protective sensation in the great toes and 2nd metatarsal heads bilaterally (unable to feel 10g monofilament).
**Observed Gait:** Stable gait, no obvious antalgic or pathological patterns.
Assessment Tools Administered:
10g monofilament testing performed, indicating loss of protective sensation in forefoot bilaterally.
Client Goals:
Patient's stated goals include maintaining current mobility, preventing foot complications associated with diabetes, and understanding how to best care for his feet at home. Expresses a desire to reduce the occasional sharp pain in his left great toe.
Summary of Assessment:
High-risk foot in a patient with poorly controlled diabetes, evidenced by loss of protective sensation (neuropathy) in the forefoot. Mild hallux valgus noted. No current ulceration or acute infection. Occasional neuropathic pain in the left great toe.
Plan / Recommendations:
**Wound Care:** No active wounds requiring debridement.
**Dressing Advice:** Not applicable currently.
**Referral:** Refer to diabetic clinic for review of glycaemic control. Consider referral to pain management for neuropathic pain if conservative measures are ineffective.
**Education:** Extensive education provided on daily foot checks, appropriate footwear choices (emphasising wide toe box and good cushioning), and the importance of reporting any new foot changes immediately. Advised on moisturising dry skin.
**Footwear Modification:** Advised to continue wearing well-fitting athletic shoes and consider seeking specialist shoe advice if current formal shoes cause discomfort.
**Pressure Offloading:** No immediate need for offloading devices.
**Follow-up Review:** Review in 3 months for re-assessment of neuropathic symptoms and general foot health. Advised to return sooner if any concerns arise.
Date: 1 November 2024
Initial Podiatry Assessment – Outpatient
Reason for Referral:
[outline the primary reason for referral to outpatient podiatry including source and clinical context, e.g. diabetic foot screening, non-healing ulcer, footwear concerns, or community clinic referral]
(Only include if explicitly mentioned in transcript or context, else omit section entirely.)
Presenting Foot/Lower Limb Concerns:
[describe pain, ulceration, deformity, gait issues, footwear problems, or any presenting symptoms reported by the patient or referring clinician]
(Only include if explicitly mentioned in transcript or context, else omit section entirely.)
Medical and Surgical History:
[include relevant comorbidities such as diabetes mellitus, hypertension, HIV, peripheral vascular disease, osteoarthritis, previous amputations, or lower limb surgeries]
(Only include if explicitly mentioned in transcript or context, else omit section entirely.)
Functional Status and Mobility:
[describe the impact of foot or lower limb issues on walking distance, use of assistive devices, balance, ability to access taxis or clinics, or need for home support]
(Only include if explicitly mentioned in transcript or context, else omit section entirely.)
Footwear and Orthoses:
[document current footwear use (e.g. flip-flops, takkies, formal shoes), condition, appropriateness for foot shape and mobility needs, and any orthotic use from state or private sources]
(Only include if explicitly mentioned in transcript or context, else omit section entirely.)
Podiatric Examination:
[include findings from physical examination including foot posture, skin condition (e.g. fissures, callus, dryness), nail health, signs of infection, pulses, capillary refill, temperature, monofilament sensation, or observed gait]
(Only include if explicitly mentioned in transcript or context, else omit section entirely.)
Assessment Tools Administered:
[include monofilament testing (10g), Doppler/ABPI where available, pressure risk tools (e.g. Inlow score), or plantar pressure assessment]
(Only include if explicitly mentioned in transcript or context, else omit section entirely.)
Client Goals:
[document client’s stated or implied goals regarding comfort, pain reduction, wound healing, mobility improvement, footwear support, or home care management]
(Only include if explicitly mentioned in transcript or context, else omit section entirely.)
Summary of Assessment:
[summary of podiatric findings and clinical interpretation, e.g. high risk foot in poorly controlled diabetic, plantar ulcer secondary to pressure, hallux valgus causing footwear issues]
(Only include if explicitly mentioned in transcript or context, else omit section entirely. Never come up with your own assessment or impression.)
Plan / Recommendations:
[include proposed management such as wound debridement, dressing advice, referral to diabetic clinic, education on foot hygiene, footwear modification, pressure offloading, or follow-up review]
(Only include if explicitly mentioned in transcript or context, else omit section entirely. Never come up with your own plan or recommendations.)
(Use as many lines, paragraphs or bullet points, depending on the format, as needed to capture all the relevant information from the transcript.)
(Never come up with your own patient details, assessment, plan, interventions, evaluation, and plan for continuing care - use only the transcript, contextual notes or clinical note as a reference for the information included in your note. If any information related to a placeholder has not been explicitly mentioned in the transcript, contextual notes or clinical note, you must not state the information has not been explicitly mentioned in your output, just leave the relevant placeholder or omit the placeholder completely.)