What is the best course of action for a diabetic patient with a history of callus formation and neuropathy who is requesting diabetic shoes?

SOAP Note for Diabetic Patient Requesting Therapeutic Footwear

SUBJECTIVE

Chief Complaint: Patient with diabetes requesting diabetic shoes

History of Present Illness:

• Patient reports history of callus formation on plantar surfaces 1
• Presence of diabetic peripheral neuropathy with associated symptoms 1
• Document specific neuropathic symptoms: numbness, tingling, burning sensations, or pain 1
• Assess for any current or prior foot ulcerations 1
• Inquire about history of prior amputation or Charcot foot 1
• Document smoking history and exercise tolerance 1
• Assess for symptoms of claudication or rest pain 1

Past Medical History:

• Duration of diabetes diagnosis 1
• Current glycemic control status and most recent HbA1c 2
• Presence of other microvascular complications: retinopathy, nephropathy 1
• History of cardiovascular disease 1

Current Medications:

• Document all diabetes medications and adherence 2

OBJECTIVE

Vital Signs: [Document blood pressure, heart rate, weight]

Comprehensive Foot Examination:

Skin Inspection:

• Document location, size, and characteristics of callus formation 1
• Assess for erythema, warmth, or hemorrhage under callus (indicates impending tissue breakdown) 1
• Examine skin integrity between toes and under metatarsal heads 1
• Check for xerosis, fissures, or erosions 3
• Document any active ulcerations or signs of infection 1

Neurological Assessment (Loss of Protective Sensation):

• Perform 10-g monofilament testing at multiple plantar sites 1
• Add at least one additional test: pinprick sensation, temperature perception, vibration with 128-Hz tuning fork, or ankle reflexes 1
• Absent monofilament sensation plus one other abnormal test confirms LOPS 1

Structural Assessment:

• Document foot deformities: hammertoes, prominent metatarsal heads, bunions, Charcot joint 1
• Assess limitation in joint mobility 1
• Evaluate gait and balance 1

Vascular Assessment:

• Palpate dorsalis pedis and posterior tibial pulses bilaterally 1
• Assess capillary refill time 1
• Check for rubor on dependency and pallor on elevation 1
• If pulses diminished or absent, obtain ankle-brachial index 1

Laboratory Data:

• Most recent HbA1c value 2
• Serum creatinine and eGFR if available 4

ASSESSMENT

Primary Diagnosis: Diabetes mellitus with peripheral neuropathy and callus formation, high-risk foot 1

Risk Stratification: This patient meets high-risk criteria for foot ulceration based on the presence of neuropathy with LOPS and callus formation 1. The relative risk of ulceration is 11.0 with callus presence and significantly elevated with neuropathy 5. Callus formation indicates areas of increased plantar pressure and impending tissue breakdown 1, 3.

Supporting Evidence:

• Loss of protective sensation confirmed by monofilament testing 1
• Callus formation present (highly predictive of subsequent ulceration) 5
• [Document any additional risk factors: foot deformities, prior ulceration, PAD, smoking] 1

PLAN

1. Therapeutic Footwear Prescription

The use of specialized therapeutic footwear is strongly recommended and medically necessary for this patient 1. This patient meets criteria as a high-risk individual with loss of protective sensation and callus formation 1.

Specific Footwear Recommendations:

• For neuropathy with callus but no significant deformities: Well-fitted therapeutic walking shoes or athletic shoes that cushion feet and redistribute plantar pressure 1
• For bony deformities (hammertoes, prominent metatarsal heads, bunions): Extra-wide or extra-depth therapeutic shoes 1
• For severe deformities or Charcot foot: Custom-molded shoes 1

Prescription Details:

• Prescribe depth-inlay shoes with custom molded inserts (if deformities present) or prefabricated inserts (if no deformities) 6
• Include 3 pairs of diabetic socks 6
• Document medical necessity based on presence of neuropathy and callus formation 1

2. Callus Management

Immediate callus debridement is indicated 1. The presence of callus with underlying neuropathy creates a relative risk of 11.0 for ulcer development 5.

• Refer to podiatrist or foot care specialist for scalpel debridement 1, 4
• Schedule regular debridement appointments every 4-8 weeks 6
• Avoid patient self-debridement due to risk of injury with neuropathy 1

3. Glycemic Optimization

• Review current diabetes management and adjust as needed to achieve target HbA1c 1, 2
• Optimal glucose control is the only intervention proven to slow neuropathy progression 2

4. Patient Education

Provide comprehensive foot self-care education 1:

• Daily foot inspection using mirror for plantar surfaces 1
• Never walk barefoot, even indoors 6
• Check inside shoes for foreign objects before wearing 3
• Wash feet daily and dry thoroughly, especially between toes 1
• Apply moisturizer to prevent xerosis but avoid between toes 3
• Trim toenails straight across 1
• Report any redness, warmth, blisters, or breaks in skin immediately 1
• Wear prescribed therapeutic footwear at all times when ambulatory 1, 6

5. Follow-up and Monitoring

This patient requires frequent monitoring due to high-risk status 1:

• Visual foot inspection at every clinical visit (every 1-3 months) 1
• Comprehensive foot examination with monofilament testing every 3-6 months 1, 4
• Annual vascular assessment 1

6. Multidisciplinary Referrals

• Podiatry referral for ongoing preventive care and lifelong surveillance 1, 4
• Consider endocrinology referral if glycemic control inadequate 2
• Vascular surgery referral if PAD suspected (absent pulses, claudication) 1, 4

7. Additional Preventive Measures

• Smoking cessation counseling if applicable 1
• Blood pressure and lipid management 2
• Screen for and correct vitamin B12 deficiency 2

Critical Pitfall to Avoid: Do not delay therapeutic footwear prescription in patients with documented neuropathy and callus formation, as this combination carries a 56.8 relative risk for ulceration if prior ulceration history exists and 11.0 relative risk with callus alone 5. The presence of callus is a "high-risk" factor requiring immediate intervention 5.