Morning Rounds Examination Proforma for Diabetic Patients with Foot Complications
For diabetic patients with a history of foot complications, morning rounds examination must include a structured assessment covering history, dermatological inspection, neurological testing, vascular evaluation, and musculoskeletal assessment at every visit. 1
Historical Assessment
Obtain the following critical historical elements:
- Prior foot complications: Document any history of ulceration, amputation, Charcot foot, angioplasty, or vascular surgery 1
- Neuropathic symptoms: Ask specifically about pain, burning sensations, and numbness 1
- Vascular symptoms: Assess for leg fatigue, claudication, rest pain, and decreased walking speed 1, 2
- Comorbid conditions: Document presence of retinopathy, renal disease (especially dialysis patients), and visual impairment 1, 3
- Tobacco use: Current smoking status as a modifiable risk factor 1, 3
- Foot care practices: Daily inspection habits and footwear behaviors 1
Dermatological Inspection
Perform a thorough skin examination looking for:
- Ulcerations and pre-ulcerative lesions: Any breaks in skin integrity 2, 3
- Callus formation: Areas of increased plantar pressure 2, 3
- Color changes: Hyperemia, erythema, warmth, or areas of pallor 1, 2
- Skin integrity: Dryness, scaling, or fungal infections 2
- Temperature differences: Palpate for warmth indicating inflammation 4
- Edema: Document any swelling 3
Neurological Assessment
The neurological examination must include 10-g monofilament testing plus at least one additional sensory test to identify loss of protective sensation (LOPS): 1, 2
- 10-g Semmes-Weinstein monofilament test: Test at plantar sites; absent sensation indicates LOPS 2, 3
- Additional testing options (choose at least one):
Interpretation: At least two normal tests with no abnormal tests rules out LOPS; absent monofilament sensation suggests LOPS 1
Vascular Assessment
Perform comprehensive vascular evaluation including:
- Pedal pulse palpation: Assess dorsalis pedis and posterior tibial arteries 1, 2
- Additional vascular signs (if compromise suspected):
- Ankle-brachial index: Perform if symptoms or signs of peripheral arterial disease are present 1, 3
Musculoskeletal Assessment
Document any structural deformities that increase ulceration risk:
- Bony deformities: Hammertoes, claw toes, bunions, prominent metatarsal heads 2, 3
- Charcot foot: Midfoot collapse or rocker-bottom deformity 1, 3
- Limited joint mobility: Assess ankle and foot range of motion 3
- Foot structure: Flat feet (pes planus) or other architectural abnormalities 2
Risk Stratification Documentation
Classify the patient's risk category at each examination:
- Very low risk: No LOPS, no peripheral arterial disease 2
- Category 1: Peripheral neuropathy alone 3
- Category 2: Neuropathy with peripheral arterial disease and/or foot deformity 3
- Category 3 (High risk): LOPS or peripheral arterial disease with history of foot ulcer, amputation, or end-stage renal disease 2, 3
Footwear Assessment
Examine current footwear at each visit:
- Appropriateness: Well-fitted shoes for low-risk patients; therapeutic footwear with custom insoles for Category 2 patients; custom-molded shoes for severe deformities 1, 3
- Compliance: Document whether patient is wearing prescribed therapeutic footwear consistently 3
- Condition: Inspect for wear patterns, foreign objects, or rough areas inside shoes 3
Common Pitfalls to Avoid
Do not rely on patient symptoms alone in diabetic patients with neuropathy, as they may not perceive pain or injury due to LOPS 5. The pathology can progress rapidly to necrosis without typical warning signs 5.
Do not skip the examination even if the patient reports no problems—foot inspection should occur at every visit for all diabetic patients 1. High-risk patients (Category 3) require examination every 1-3 months 3, 4.
Do not perform monofilament testing alone—guidelines specifically require at least one additional sensory test for accurate LOPS diagnosis 1, 2.