Symptoms
Neurological Symptoms
Client is queried regarding experience of neurological symptoms:
None/ Paraesthesia/ Dysesthesia/ Anaesthesia/ Stereognosis/ Undetermined
Client is queried on frequency of these symptoms:
None/ Occasional/ Frequent/ Constant/ Unable to Determine
Neurological Treatment
A choice is made from the following list:
None/ Topical Physical/ Topical Chemical/ TENS/ Anti-epileptics/ Anti-depressants/ Other/ Unable to Determine
Vascular Symptoms
Client is queried regarding experience of cramping/ pains in legs/ feet:
None/ Intermittent Claudication/ Rest Pain/ Cramping Occasional/ Cramping Frequent
Trophic Changes
Assessment of feet and legs for signs of circulation problems
None/ Skin Atrophy/ Hair Atrophy/ Nail Atrophy
Foot Assessment
Tests are conducted on client's feet for signs of complications associated with diabetes:
Vibratory Threshold
Graduated tuning fork placed on tip of hallux. Test of client's ability to detect vibration sensation, carried on larger nerve fibres
Measured in octals
< 4 / 8 octals indicates impairment
Plantar Reflex
A pointed object is used to stimulate the plantar lateral aspect of foot in a single motion from heel to 5th MTP joint area. Commonly regarded as a Babinski test.
Measures plantar reflex indicating changes to motor nerves at local level Present/ Absent/ Diminished/ Increased
Soleal Reflex
The ankle reflex is assessed using a reflex hammer to assess if motor nerves are firing at the local level.
Present/ Absent/ Diminished/ Increased
Monofilament
A range of Semmes Weinstein monofilaments in graduated diameters and grams are used to assess ability to detect light touch.
Inability to detect 10grams pressure (5.07 diameter monofilament) is a reliable indicator of loss of protective sensation and thus client is at high risk of potential ulceration/ undetected trauma.
0.05/ 0.2/ 2.0/ 4.0/ 10.0/ 300.0/ Unable To Determine
Peripheral Neuropathy
Evaluation of above tests conducted provide podiatrist with evidence of nerve damage to distal nerves.
None/ Digital/ Forefoot/ Ankle/ Lower 1/3 Tibia/ Tibial Tuberosity/ Unable to Determine
Pulses
Dorsalis Pedis and Posterior Tibial Pulse:
Dorsalis Pedis pulse is palpated on foot. Assists in evaluating presence of PVD.
Bounding pulses may be present in peripheral neuropathy
Nil pulse/ Diminished/ Normal/ Bounding
Ankle Brachial Index
Only measured if pertinent to client's presenting condition.
Value entered
Foot Deformity
Podiatrist assesses for presence of bony prominences, deformities which place the foot at risk of trauma. Also to assess need for special footwear.
A choice is made from the following list:
Digital/ Hallux/ Forefoot/ Midfoot/ Rearfoot/ Other
Deformity Cause
A choice is made from the following list:
None/ Charcot's arthropathy/ Biomechanical/ Footwear/ Surgery/ Other
Amputated in Last 12 Months
A choice is made from the following list: No/ Yes
Amputation Level
Only appears if amputation selected.
A choice is made from the following list:
Hallux/ Lesser Digit/ Ray/ Forefoot/ Ankle/ Below Knee/ Above Knee
Podiatry Specific History
Some fields only appear on the report if they are relevant to the client.
Foot Specific Hospitalisation since last assessment
A choice is made from the following list: Yes/ No
Cause of Hospitalisation:
A choice is made from the following list:
Infected ulceration/ Cellulitis/ Amputation/ Surgical Debridement of an Ulcer/ Non-Diabetes related Trauma/ Osseous Reconstructive Surgery/ Unknown/ Other
Conditions Since Last Assessment
A choice is made from the following list:
None/ Mycotic/ Onychomycotic/ Bacterial/ Unknown/ Osteomyelitis/ Specific ulcer/ Other
Gangrene displays if selected
Dermal Foot Infection
A choice is made from the following list:
None/ Mycotic/ Onchomycotic/ Bacterial/ Unknown/ Other
Ulceration
Current Foot Ulceration
A choice is made from the following list: None/ Yes Current/ Yes Previous
Ulceration Type
A choice is made from the following list:
Neuropathic/ Vascular/ Mixed/ Surgical/ Pressure/ Unable to determine/ Other
Number of Active Ulcerations
Number will be entered
Osteomyelitis
A choice is made from the following list:
Don't know/ No/ Probable/ Definite/ Unable to Determine
Osteomyelitis Diagnosis
If Definite is selected above, then podiatrist must select the method of diagnosis.
Radiographs/ Bone Scan/ Labelled Bone Scan/ Other
Location of Ulceration
Location of ulcer will be shown as selected by podiatrist
Ulceration Treatment
A choice is made from the following list:
Hospitalisation/ Wound care/ Routine debridement/ Surgical debridement/ Temporary insole/ Temporary footwear/ Specialist footwear/ Vascular reconstruction/ Rehabilitation therapy/ Dermagraft (skin graft)/ Other
Ulceration Infection
A choice is made from the following list: Yes/ No/ Unknown
Treatment of Infection
A choice is made from the following list:
Topical/ Oral ABx/ Systemic ABx (hospital) Systemic ABx (Hospital in the Home)/ Unknown
Duration of Lesion (Actual)
Duration of Lesion (Treatment)
Client may have a period between the lesion appearing and seeking treatment
Assigned Risk Factor
A choice is made from the following list:
Low risk/ At risk/ High risk/ Low risk specific
Risk level evaluated as result of above assessment
Low risk = no pedal risk factors
At risk = no pedal risk factors, but client may have reasons to be unable to self care/ no carer able to care for feet
High risk = pedal risk factors present eg: PVD/ peripheral neuropathy
Low risk Specific = no pedal risk factors, but there may be a specific condition that requires further treatment by podiatrist – either ACTCC or private podiatrist