Initial Podiatry Assessment

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