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Diabetic Foot Ulcer (DFU) Clerking Template

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1. PRESENTING COMPLAINT

• Location of ulcer/wound on foot
• Duration present
• How it was first noticed (or went unnoticed due to neuropathy)
• Triggering factor (ill-fitting footwear, minor trauma, spontaneous)

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2. HISTORY OF PRESENTING COMPLAINT

Wound characteristics

• Size (width, depth)
• Discharge — purulent, serous, bloody, none?
• Odour
• Change over time — improving, worsening, stable?
• Previous episodes of ulceration at the same or other sites

Symptoms of infection

• Redness / erythema — extent from wound edge
• Warmth
• Swelling / induration
• Pain or tenderness (note: absence does NOT exclude infection in neuropathic feet)
• Purulent discharge
• Crepitation (gas in tissue)
• Fever, rigors, sweating (systemic features → SIRS)

Neuropathy symptoms

• Loss of sensation / numbness in feet or legs
• Paraesthesiae (tingling, burning, "pins and needles")
• Burning pain, worse at night
• Balance problems, falls
• Has patient noticed the ulcer themselves, or was it found by someone else?

Peripheral vascular disease symptoms

• Intermittent claudication — distance, muscle group (calf, thigh, buttock)
• Rest pain (worse lying, relieved hanging foot down)
• Colour changes — pallor on elevation, dependent rubor
• Non-healing cuts / previous ulcers elsewhere
• History of coronary artery disease / stroke / TIA (markers of systemic atherosclerosis)

Structural / biomechanical factors

• Foot deformity: bunions (hallux valgus), hammer toes, claw toes, Charcot foot
• History of previous amputation (toe, ray, partial foot)
• Callus formation over pressure points
• Footwear: tight shoes, ill-fitting insoles, walking barefoot

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3. DIABETIC HISTORY

• Type of diabetes (Type 1 / Type 2) and duration
• Current glycaemic control — last HbA1c, home glucose readings
• Previous DFUs or amputations
• Known microvascular complications: nephropathy (CKD/dialysis), retinopathy, neuropathy
• Known macrovascular complications: IHD, stroke, PVD
• Current diabetes medications (insulin, oral agents)

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4. PAST MEDICAL HISTORY

• Hypertension
• Dyslipidaemia
• CKD / end-stage renal disease (ESRD) — worsens small vessel disease
• Immunosuppression (transplant, chronic steroids — increases infection severity)
• Previous cardiac or vascular surgery
• Osteomyelitis — prior episodes at same site?

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5. DRUG HISTORY & ALLERGIES

• Insulin / oral hypoglycaemics
• Antiplatelets (aspirin, clopidogrel)
• Statins
• Antihypertensives
• Antibiotics — recent courses (guides microbial resistance)
• Anticoagulants
• Immunosuppressants
• Allergies (especially antibiotic allergies — critical for DFI treatment planning)

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6. SOCIAL HISTORY

• Smoking (current, ex, pack-years) — key PAD risk factor
• Alcohol
• Functional status: mobilising independently, wheelchair, housebound?
• Home support: can patient do daily wound inspection? Is there a carer?
• Access to follow-up (daily follow-up essential for mild infections treated outpatient)
• Footwear / occupation / activity level
• Nutrition — diet history, weight loss, malnutrition risk

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7. SYSTEMS REVIEW

• Constitutional: fever, weight loss, malaise
• Cardiovascular: chest pain, dyspnoea, palpitations
• Renal: decreased urine output, oedema (wound maceration may be fluid-overload related)
• Respiratory: dyspnoea (relevant if surgical debridement / anaesthesia planned)

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8. EXAMINATION

Vital signs

• Temperature (>38°C or <36°C = SIRS criterion)
• Heart rate (>90 bpm = SIRS criterion)
• Respiratory rate (>20/min = SIRS criterion)
• Blood pressure
• Capillary blood glucose

Wound assessment (WIfI — Wound)

• Document: location, size (cm), depth (probe with back of cotton swab — probe-to-bone test)
• Debride callus before full assessment
• Assess: base colour (granulating / sloughy / necrotic / bone visible), edges, surrounding skin, discharge, odour
• Signs of infection: erythema (measure extent from wound edge), warmth, swelling, purulence, crepitation

Neurological examination

• 10-g monofilament test (4 sites on each foot)
• Vibration sensation — 128 Hz tuning fork (great toe)
• Ankle reflexes
• Proprioception

Vascular examination (WIfI — Ischaemia)

• Femoral, popliteal, dorsalis pedis, posterior tibial pulses
• Capillary refill time
• Skin: pallor, dependent rubor, hair loss, shiny skin, trophic changes
• Ankle-brachial index (ABI) — note: may be falsely elevated due to medial calcinosis in diabetics; toe pressures more reliable
• Pulse volume recordings (PVRs)

Foot structure

• Deformities: hallux valgus, hammer/claw toes, Charcot joint
• Calluses — location
• Prior amputation sites
• Both feet examined

IWGDF/IDSA Infection Classification (WIfI — foot Infection)

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9. INVESTIGATIONS

Bedside

• Capillary blood glucose / point-of-care HbA1c
• Probe-to-bone test (positive = high PPV for osteomyelitis)

Bloods

• FBC (leukocytosis, anaemia)
• CRP, ESR (support diagnosis of infection; elevated levels correlate with severity)
• U&E / eGFR (renal function — affects antibiotic dosing; CKD worsens prognosis)
• LFTs
• HbA1c
• Lipid profile
• Coagulation (if surgical intervention planned)
• Blood cultures (if SIRS/fever present)

Microbiology

• Deep tissue swab or tissue biopsy (NOT superficial swab — avoids colonisers)
• Bone culture if osteomyelitis suspected (guides antibiotic duration and selection)

Imaging

• Plain x-ray foot (3 views): bone erosion, foreign bodies, soft tissue gas, Charcot changes, prior amputations, heterotopic ossification
• MRI foot: gold standard for early osteomyelitis detection
• CT: identifies deeper abscesses when MRI unavailable
• Angiography (CT angiogram / formal angiogram) if revascularisation being considered

Vascular

• ABI + toe pressures
• Transcutaneous oxygen measurement (TcPO₂) — <40 mmHg indicates impaired wound healing and potential indication for hyperbaric oxygen

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10. SUMMARY IMPRESSION

• Wound grade (0–3)
• Ischaemia grade (0–3)
• fI (foot Infection) grade (1–4)

1. Risk of major lower extremity amputation at 1 year
2. Likely benefit of revascularisation

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11. MANAGEMENT PLAN (document thinking)

• Glycaemic optimisation
• Wound care: moist environment, debridement of callus/necrotic tissue, offloading (orthotic device, total contact cast)
• Antibiotics: oral for mild (gram-positive cover); IV broad-spectrum for moderate–severe (e.g., piperacillin-tazobactam + vancomycin)
• Osteomyelitis: 6-week antibiotic course if no surgical resection
• Surgical referral: urgent if necrotising infection, deep abscess, compartment syndrome, or limb ischaemia
• Vascular surgery referral: if ischaemia grade ≥1 with non-healing wound at 4–6 weeks
• Hyperbaric oxygen: consider if TcPO₂ <40 mmHg and wound not healing
• Daily follow-up for outpatients; hospitalisation if systemic features or inadequate home support
• Long-term follow-up: minimum 1 year to confirm remission

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