tailieunhanh - Appendix 1 (Part 1): Diabetic Foot Evaluation

Type 1 Type 2 Rx - Insulin - Incretin - Oral Hypoglycemic - Diet Diabetes duration Attending MD Height BP Weight Date: Age: History of: HbA1C Foot Ulcer Infection Amputation Revascularization Renal Disease CAD Stroke Tobacco Alcohol Numbess Burning Paresthesia/Tingling Sharp Pain Night Pain Muscle Weakness Gait Difficulties Claudication toes plantar feet to above ankle . to below knee night daily occasionally wheelchair walker cane brace foot orthosis MDI Shoes Skin: Turgor Color Temperature Texture Fissures Corns Calluses Ulcers Lesions Nails Musculoskeletal Mark areas of callus, ulcer or pre-ulcer, erythema, swelling, tenderness or deformity Joint Flexibility Deformities or Sites of High Pressure Gait assessment . | Appendix 1 pl S-50 Patient Chart Date Diabetic Foot Evaluation _ Age __ Mark areas of callus ulcer or pre-ulcer erythema swelling tenderness or deformity THE JOURNAL OF FOOT ANKLE SURGERY Medications Type 1 Type 2 Rx - Insulin - Incretin - Oral Hypoglycemic - Diet Diabetes duration Attending MD ---------------------------------- Height Weight __ BP _ HbA1C History of Foot Ulcer -------------- Infection __ Amputation Revascularization __ Renal Disease CAD -------------- Stroke __ Tobacco __ Alcohol Paresthesia Tingling Numbess toes plantar feet to above ankle Burning . to below knee Sharp Pain Night Pain Muscle Weakness night daily occasionally Gait Difficulties wheelchair Claudication walker cane brace Shoes foot orthosis MDI Skin Turgor Color Temperature Texture Lesions Fissures Corns Calluses Ulcers Nails Musculoskeletal Joint Flexibility ------------------------------ Deformities or Sites of High Pressure Gait assessment Appendix 1 p2 Neurologic Exam Sensory - Semmes-Weinstein Monofilament Ability to detect or 10 gm Monofilament or - Deep Tendon Reflexes Present - Absent Right Left Patella __ __ Achilles Vascular Exam Right Left Pulse Exam Pulses 0 absent Dorsalis Pedis 0 1 2 3 0 1 2 3 1 diminished Posterior Tibial 0 1 2 3 0 1 2 3 2 3 normal bounding Elevation Pallor Absent Present Absent Present Dependent Rubor Absent Present Absent Present Capillary Filling Time 1 1-3 3 1 1-3 3 Edema Absent Risk Status 0 No Sensory Neuropathy No PAD Negative Hx of Foot Ulcer I Neuropathy LOPS No PAD No Deformity II Sensory Neuropathy PAD or Foot Deformity III Previous Foot Ulcer or Amputation Prior Ulceration or Amputation Charcot Deformity - Location Recommended .