CLINICAL PODOGERIATRIC ASSESSMENT

ARTHUR E HELFAND, DPM
Professor Emeritus, Temple University
School of Podiatric Medicine
email: Aehelfand@aol.com

INTRODUCTION

The initial clinical pedal assessment of the geriatric patient has been developed as a Comprehensive Podogeriatic and Chronic Disease Assessment protocol to augment geriatric and chronic disease assessment. The objective was to develop a process to identify foot and related problems and stratify risk, for those potential foot problems that might develop as complications of chronic diseases, associated with older patients. The goal to the protocol's application is one primarily of secondary prevention. Its utilization also stresses the need for patient and professional education as well as the need for appropriate management, by those licensed to provide and maintain the highest level of quality care and concern. The protocol included a compilation of various procedures and clinical impressions that also included Medicare’s “at risk” criteria for management.

Much of the ability to remain ambulatory in the period of aging is directly related to foot health. In order to accomplish this aim, practitioners must think comprehensively, and recognize that team care must be an essential part of chronic disease management the care of the older patient. Foot health education, including programs developed by the Pennsylvania Diabetes Academy of Pennsylvania, are available to both patients and professionals, and should be employed. It is clear that adults with chronic disease and older patients are a high risk for foot related disease and should maintain continuing foot assessment, education, surveillance, and care. For this population, the ability to prevent complications and maintain mobility and ambulation will be reflected in their quality of life and their ability to remain mentally alert and active in their communities.

The Pennsylvania Department of Health as a part of its Diabetes Control Program contracted Temple University, School of Podiatric Medicine to develop and validate a protocol for podogeriatric assessment. In cooperation with the Pennsylvania Diabetes Academy, and in cooperation with the Institute on Aging of Temple University; the Division of Endocrinology, Diabetes and Metabolic Diseases, Department of Medicine, Jefferson Medical College; and the Institute on Aging, University of Pennsylvania, a protocol was developed to provide an initial assessment and follow-up evaluation protocol and form that would establish foot health and care needs and help prevent pain, disability, complications and help older patients retain their dignity and independence.

Published on the web with permission from ARTHUR E HELFAND, DPM, Professor Emeritus, Temple University, School of Podiatric Medicine. For more infomation, please contact Dr. Helfand at Aehelfand@aol.com

 

 

PODOGERIATRIC ASSESSMENT AND CHRONIC DISEASE PROTOCOL

DATE OF VISIT MR#
PATIENT'S NAME AGE
DATE OF BIRTH SOCIAL SECURITY NUMBER:
ADDRESS
CITY STATE ZIP CODE
PHONE  
SEX
MALE
FEMALE
RACE
B
W
A
L
NA
WEIGHT

LBS

 HEIGHT
IN
MARITAL STATUS:
M
S
W
D
SEP

NAME OF PRIMARY PHYSICIAN/HEALTH CARE FACILITY:

 
DATE OF LAST VISIT:
 
HISTORY OF PRESENT ILLNESS
Swelling of Feet Location
Painful Feet
Quality
Hyperkeratosis
Severity
Onychial Changes Duration

Bunions
Context
Painful Toe Nails Modifying Factors
Infections Associated Signs & Symptoms
Cold Feet  
Other  
 

* = Notations marked with ASTERIKS denote qualifiers for Therapeutic Shoes under the Medicare Program for Medicare "at risk" patients with Diabetes Mellitus. Those Criteria include:

  • History of partial or complete amputation of the foot
  • History of previous foot ulceration
  • History of pre-ulcerative callus
  • Peripheral neuropathy with evidence of callus formation
  • Foot Deformity
  • Poor Circulation
 
PAST HISTORY
Heart Disease Diabetes Mellitus
High Blood Pressure * IDDM
Arthritis * NIDDM
* Circulatory Disease Hypercholesterol
Thyroid Gout
Allergy History: Smoking: OH
Infections Family - Social
 
SYSTEMS REVIEW
Constitutional    
ENT Card/Vasc GU
Eyes Musculo-Skeletal Neurologic
Skin/Hair   Endocrine
Respiratory GYN GI
Psychiatric Allergic Immunologic
Hematologic Lymphatic  
 
MEDICATIONS
 
 
 
 
 
 
DERMATOLOGIC
* Hyperkeratosis Xerosis
Onychauxis B-2-b Tinea Pedis
Infection Verruca
* Ulceration Hematoma
Onychomycosis Rubor
Onychodystrophy * Preulcerative
* Cyanosis B-2-e Discolored
 
FOOT ORTHOPEDIC
* Hallux Valgus * Hallux Rigidus-Limitus
* Anterior Imbalance * Morton's Syndrome
* Digiti Flexus Bursitis
* Pes Planus * Prominent Met Head
* Pes Valgoplanus * Charcot Joints
* Pes Cavus Other Other
 
VASCULAR EVALUATION
* Coldness C-2 * Claudication C-1
* Trophic Changes B-2-a Varicosities
* DP Absent B-3 Other
* PT Absent B-1 * Amputation
* Night Cramps * AKA BKA FF T A-1
* Edema C-3 Atrophy B-2-d
 
NEUROLOGIC EVALUATION
* Achilles Superficial Plantar
* Vibratory * Joint Position
* Sharp/Dull * Burning C-5
* Paresthesia C-4 Other
 
RISK CATEGORY - NEUROLOGIC
0
 = No Sensory Loss
* 1
 = Sensory Loss
* 2
 = Sensory Loss & Foot Deformity
* 3
 = Sensory Loss, Hx Ulceration, & Deformity
 
RISK CATEGORY - VASCULAR
0 - 0
 NO CHANGE
* I - 1
 MILD CLAUDICATION
* I - 2
 MODERATE CLAUDICATION
* I - 3
 SEVERE CLAUDICATION
* II - 4
 ISCHEMIC REST PAIN
* III - 5
 MINOR TISSUE LOSS
* III - 6
 MAJOR TISSUE LOSS
 
CLASS FINDINGS
A1
 Nontraumatic Amputation
B1
 Absent Posterior Tibial
B2
 Advanced Trophic Changes
B2a
 Hair Growth (decrease or absent)
B2b
 Nail Changes (thickening)
B2c
Pigmentary Changes (discoloration)
B2d
 Skin Texture (thin, shiny)
B2e
 Skin Color (rubor or redness)
B3
 Absent Dorsalis Pedis
C1
 Claudication
C2
 Temperature Changes (cold)
C3
 Edema
C4
 Paresthesia
C5
 Burning
 
ONYCHOMYCOSIS: Documentation of mycosis/dystrophy causing secondary infection and/or pain, which results or would result in marked limitation of ambulation.
Discoloration  
Hypertrophy  
Subungual Debris  
Onycholysis  
Secondary Infection  
Limitation of Ambulation and Pain  
 
CLASSIFICATION OF MECHANICAL OR PRESSURE HYPERKERATOSIS
GRADE DESCRIPTION
0
 NO LESION
1
 NO SPECIFIC TYLOMA PLAQUE,
BUT DIFFUSE OR PINCH HYPERKERATOTIC TISSUE PRESENT OR IN NARROW BANDS
2
 2 CIRCUMSCRIBED, PUNCTATE OVAL, OR CIRCULAR, WELL DEFINED
THICKENING OF KERATINIZED TISSUE
3
 HELOMA MILLIARE OR HELOMA DURUM WITH NO ASSOCIATED TYLOMA
4
 WELL DEFINED TYLOMA PLAQUE WITH A DEFINITE HELOMA WITHIN THE LESION
5
 EXTRAVASATION, MACERATION AND EARLY BREAKDOWN OF STRUCTURES
UNDER THE TYLOMA OR CALLUS LAYER
6
 COMPLETE BREAKDOWN OF STRUCTURE OF HYPERKERATOTIC TISSUE, EPIDERMIS, EXTENDING TO SUPERFICIAL DERMAL INVOLVEMENT
 
PLANTAR KERATOMATA PATTERN
LT
5
4
3
2
1
RT
1
2
3
4
5
 
ULCER CLASSIFICATION
GRADE - 0 ABSENT SKIN LESIONS
GRADE - 1 DENSE CALLUS BUT NOT PRE-ULCER OR ULCER
GRADE - 2 PREULCERATIVE CHANGES
GRADE - 3 PARTIAL THICKNESS (SUPERFICIAL ULCER)
GRADE - 4 FULL THICKNESS (DEEP) ULCER BUT NO INVOLVEMENT OF TENDON,
BONE, LIGAMENT OR JOINT
GRADE - 5 FULL THICKNESS (DEEP) ULCER WITH INVOLVEMENT OF TENDON,
BONE, LIGAMENT OR JOINT
GRADE - 6 LOCALIZED INFECTION (ABSCESS OR OSTEOMYELITIS)
GRADE - 7 PROXIMAL SPREAD OF INFECTION (ASCENDING CELLULITIS OR
LYMPHADENOPATHY
GRADE - 8 GANGRENE OF FOREFOOT ONLY
GRADE - 9 GANGRENE OF MAJORITY OF FOOT
 
  ONYCHIAL GRADES AT RISK
Grade I
 NORMAL
Grade II
 MILD HYPERTROPHY
Grade III
 HYPERTROPHIC
DYSTROPHIC
ONYCHAUXIS
MYCOTIC
INFECTED
ONYCHODYSPLASIA
Grade IV
 HYPERTROPHIC
DEFORMED
ONYCHOGRYPHOSIS
DYSTROPHIC
MYCOTIC
INFECTED
 
FOOTWEAR SATISFACTORY
YES NO
HYGIENE SATISFACTORY
YES NO
   
STOCKINGS
NYLON COTTON WOOL OTHER NONE

 
ASSESSMENT  
   
PLAN  
  PODIATRIC REFERRAL
  PATIENT EDUCATION
  MEDICAL REFERRAL
  SPECIAL FOOTWEAR
  VASCULAR STUDIES
  CLINICAL LAB
  IMAGING
  Rx




FOOTNOTES
NOTE 1
Foot Care services for Medicare purposes must be provided by practitioners who are permitted by state license to render examination, diagnosis, and treatment of foot diseases.

NOTE 2
Services furnished for the evaluation and management of a diabetic patient with diabetic sensory neuropathy, resulting in a Loss of Protective Sensation (LOPS) must include the following:

1. a diagnosis of LOPS
2. a patient history
3. a physical examination consisting of findings regarding at least the following elements:
a. visual inspection of the forefoot, hindfoot, and toe web spaces
b. evaluation of protective sensation
c. evaluation of foot structure and biomechanics
d. evaluation of vascular status
e. evaluation of skin integrity
f. evaluation and recommendation of footwear
4. patient education


NOTE 3
The Podogeriatric and Chronic Disease Assessment Protocol (Helfand Index) provides the components for the existing requirements provided that state licensure laws are met.

NOTE 4
Feet First, If The Shoe Fits, and Assessing The Older Diabetic Foot (CD) are available from the Pennsylvania Department of Health, Harrisburg, Pennsylvania.

Published on the web with permission from ARTHUR E HELFAND, DPM, Professor Emeritus, Temple University, School of Podiatric Medicine. Art Helfand is Retired Chair: Department of Community Health, Aging, and Health Policy, Consultant, Temple University Institute on Aging, Adjunct Professor of Medicine, Temple University, School of Medicine and Honorary Staff, Thomas Jefferson University Hospital, Temple University Hospital, Temple University Children’s Hospital. Abstracts of Dr. Helfand's publications can be accessed by visiting:
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=search&db=pubmed&term=Helfand+AE[au]&dispmax=50

For more information, please contact Dr. Helfand at Aehelfand@aol.com

A longer version of this CLINICAL PODOGERIATRIC ASSESSMENT (PDF) is also available online.

Last updated May 26, 2004