Ku - Annual Comprehensive Diabetes Foot Exam Form Page 2
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1
2Developed by JoAnn M. Peterson, MSN, ARNP
5/19/09
Annual Comprehensive Diabetes Foot Exam Form – page 2
Name _________________________________________________________________DOB _________________
Clinical Findings Cont’d
Vascular: ABI’s if absent pulses or positive vascular sx (page 1)
Neurological: Exam includes
monofilament test plus one of
L
R
the four additional sensory
Palpable Pedal Pulses
exams.
Posterior tibial
Dorsalis Pedis
Sensory Foot Exam: Label sensory
level with a “+” if the patient can feel
Ankle/Brachial Pulses (if indicated)
L
R
the 5.07 (10 gram) monofilament
Ankle
Right
Left
and “-“ if the patient cannot feel the
Brachial
filament
ABI
Add’l Neuro Exams:
ABI Interpretation: > 1.30 non-compressible; 0.91-1.30 normal; 0.41-0.90
mild to moderate PAD; 0.00-0.40 severe PAD (N Engl J Med, 344:21, 1608-
L
R
1621)
Vibratory sensation (plantar hallux)
Comments:
Pinprick sensation (dorsal hallux)
Ankle reflex (Achilles tendon)
VPT (plantar hallux)
Assessment
Plan
Risk Categorization(per LEAP program)/Foot Pathology
Medical Management
Risk Category
Definition
0
No LOPS, no PAD, no deformity
1
LOPS + deformity
2
PAD + LOPS
3
Hx of ulcer or amputation
1.______________________________________________________
2______________________________________________________
3.______________________________________________________
4.______________________________________________________
LEAP: Lower Extremity Amputation Prevention( )
Referral:
LOPS: Loss of protective sensation
Primary Care Provider
Diabetic Educator
PAD: Peripheral Arterial Disease
Endocrinologist
RN Foot Specialist
Podiatrist
Medical Nutrition Specialist
Education:
Surgeon, ankle/foot
OT
Ed of preventive foot care
Smoking cessation counseling
Surgeon, vascular
Orthotist
Ed of other DM Self-care
Other:
Other:
Pedorthist
A1c
PT
Diet, basic
Rehab. Specialist
Exercise, basic
Self blood sugar monitoring
Medications
Follow-up:
Signature:
Schedule follow-up visit:
When? ______________________
w/RN foot specialist
For?
______________________
PCP – disease management
5/19/2009
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