Documentation of Diabetic Foot Examination in a 14-Year-Old Male
For a 14-year-old male with diabetes, the diabetic foot examination should be documented using a comprehensive approach that includes inspection, assessment of foot pulses, and testing for loss of protective sensation with the 10-g monofilament and at least one additional neurological test. 1
When to Begin Foot Examinations
- For adolescents with Type 1 diabetes: Begin at puberty or ≥10 years old (whichever comes first) and after 5 years of diabetes duration 1
- For adolescents with Type 2 diabetes: Begin at diagnosis 1
- Follow-up frequency: Annually if normal; more frequently if abnormalities are detected 1
Essential Components to Document
1. General Inspection
- Document skin integrity (presence of calluses, fissures, breaks, or ulcerations)
- Note any foot deformities (bunions, hammertoes, prominent metatarsal heads)
- Check between toes for maceration or fungal infection 2
2. Neurological Assessment
- 10-g Semmes-Weinstein monofilament testing:
- Document testing at three specific sites on each foot (as shown in guidelines)
- Record whether patient correctly identifies 2 out of 3 applications at each site 1
- Additional neurological test (at least one must be performed and documented):
- Vibration sensation using 128-Hz tuning fork (applied to bony prominence of distal phalanx of first toe)
- Pinprick sensation test
- Ankle reflex assessment 1
3. Vascular Assessment
- Document palpation of dorsalis pedis and posterior tibial pulses (present/diminished/absent)
- Note capillary refill time
- Record any abnormal findings suggesting vascular compromise 2
4. Risk Stratification
- Document the patient's risk category based on findings:
- Very Low: No loss of protective sensation (LOPS) and no peripheral arterial disease (PAD)
- Low: LOPS or PAD
- Moderate: LOPS + PAD, or LOPS + foot deformity, or PAD + foot deformity
- High: LOPS or PAD with history of foot ulcer or amputation 2
Documentation Template Example
DIABETIC FOOT EXAMINATION:
History: [Document any previous foot problems, symptoms of neuropathy or vascular disease]
Inspection:
- Skin integrity: [intact/abnormal - describe]
- Deformities: [none/present - describe]
- Interdigital spaces: [normal/macerated/fungal infection]
Neurological Assessment:
- 10-g monofilament testing:
* Right foot: [sites tested and results]
* Left foot: [sites tested and results]
- Vibration sensation (128-Hz tuning fork):
* Right foot: [normal/diminished/absent]
* Left foot: [normal/diminished/absent]
Vascular Assessment:
- Dorsalis pedis pulse: Right [present/diminished/absent], Left [present/diminished/absent]
- Posterior tibial pulse: Right [present/diminished/absent], Left [present/diminished/absent]
- Capillary refill: [normal/delayed]
Risk Assessment: [Very Low/Low/Moderate/High]
Plan:
- Education provided: [specify]
- Follow-up recommended: [specify timeframe]
- Referrals: [if needed]Important Considerations for Pediatric Patients
- Documentation should acknowledge developmental considerations appropriate for a 14-year-old
- Include assessment of footwear appropriateness for adolescent activities
- Document education provided to both the patient and parents/caregivers 2
- Note any barriers to foot care compliance specific to adolescents
Common Pitfalls to Avoid
Skipping the foot exam because the patient is young - guidelines clearly indicate foot exams should begin at puberty or age 10 in type 1 diabetes and at diagnosis in type 2 diabetes 1
Incomplete neurological testing - ensure both monofilament testing AND at least one additional neurological test are performed and documented 1
Failure to document patient education - adolescents need age-appropriate education on foot care practices 2
Overlooking footwear assessment - document whether current footwear is appropriate for the patient's foot status and activity level
Not specifying follow-up frequency - clearly document when the next foot examination should occur based on risk stratification 2