Podiatry Consult Note (Inpatient/ED)

Date/Time: [Date and time of consult request and podiatry evaluation]

Location: [ED / Inpatient unit and bed]

Requesting Service: [Service name and clinician contact]

Consult Question: [Specific clinical question being addressed]

Sources of History: [Patient / Family / EMS / Chart review / Staff] (Document any limitations such as altered mental status, sedation/intubation, language barrier, or unavailable historian.)

Clinical Summary

[One-liner: patient age/sex, key comorbidities, limb issue with laterality, and precipitating context]

• Working Diagnoses: [Problem list prioritized by limb- and life-threat]
• Infection Severity: [Uninfected / Mild / Moderate / Severe] (Include only if diabetic foot infection suspected.)
• Limb-Threat Status: [No limb threat / Neurovascular concern / Ischemia / Necrosis]

Immediate Actions: [Urgent OR / Bedside source control / Emergent vascular eval / Same-day reassessment / Safe for outpatient follow-up]; [Immediate orders: NPO status, hold anticoagulation, offloading, isolation as indicated]

Pending: [Diagnostics or consultations pending with timing] (Use placeholders only for data being actively pursued. For straightforward non-urgent consults, keep this section minimal.)

History of Present Illness

[Narrative describing why the patient presented now, symptom onset and timeline, progression, precipitating factors (trauma, blister, pressure, recent surgery), local and systemic infection symptoms (fever, chills, malaise, glycemic derangements), prior wound care and offloading, prior antibiotics (agents, dates, adherence, response), prior cultures and susceptibilities if known, relevant surgical or trauma history, and why podiatry consultation is requested at this time.] (If information cannot be obtained, state the reason rather than using generic denials.)

Relevant Comorbidities

• Diabetes: [Type, duration, last A1c and date]
• Neuropathy: [Present / Absent; type if known]
• Peripheral arterial disease: [History, prior revascularization]
• CKD/ESRD: [Stage, dialysis modality if applicable]
• Immunosuppression: [Steroids / DMARDs / Biologics / Chemotherapy / Transplant / HIV]
• Smoking: [Current / Former / Never]
• Anticoagulants/Antiplatelets: [Agents and indications]

Medications and Allergies

• Antibiotic allergies: [Agents and reaction type/severity] (Highlight beta-lactams.)
• Current antimicrobials: [Agent(s), dose, route, start date, last dose]
• Diabetes medications: [Insulin regimen / Non-insulin agents]
• Steroids/Immunosuppressants: [Agents and doses]
• Anticoagulants/Antiplatelets: [Agents, doses, timing of last dose]

(Refer to full MAR for complete medication list.)

Vital Signs

Most recent: [Temp], [HR], [BP], [RR], [SpO2 on room air or supplemental O2]

Trends: [Fever curve / Tachycardia / Hypotension if relevant]

Pain score: [Score/10 and location] (Note that pain may be unreliable with neuropathy.)

Pertinent Data

Labs (reviewed): [CBC with WBC/ANC, BMP/CMP, ESR, CRP, procalcitonin if used, glucose trends, lactate if systemic concern, coagulation studies if procedure planned] (Include dates/times.)

Labs (pending): [Tests pending] (Include only if actively ordered.)

Imaging (reviewed): [Radiograph and advanced imaging key findings with laterality and dates] (Summarize findings; note hardware artifact or limitations.)

Imaging (pending): [Study, target area, indication]

Vascular studies: [ABI / TBI / Toe pressures / Doppler waveforms and date] (Note limitations such as noncompressible vessels.)

Microbiology (reviewed): [Source and specimen type: superficial swab vs deep tissue vs bone; collection date; Gram stain; culture results; susceptibilities; preliminary vs final]

Microbiology (pending): [Specimens ordered with source]

Physical Examination

(Document laterality throughout. If unable to examine fully, state the reason and plan to reassess.)

General: [Appearance, orientation, distress level]

Vascular: [Right/Left dorsalis pedis pulse: palpable / Dopplerable / absent]; [Right/Left posterior tibial pulse: palpable / Dopplerable / absent]; [Capillary refill]; [Skin temperature and color]; [Dependent rubor or pallor]; [Edema character and distribution] (Do not infer adequate perfusion from warmth alone; document uncertainty and plan for objective testing if needed.)

Neurologic: [Protective sensation method and results (monofilament sites tested, tuning fork)]; [Motor function] (Explicitly document neuropathy if present.)

Wound/Soft Tissue: (For each wound:)

• Wound [#] – [Anatomic location, laterality]: [Measurements L × W × D in cm]; [Undermining/tunneling with clock-face orientation and depth]; [Wound bed: granulation / slough / eschar with % estimates]; [Periwound: erythema extent in cm beyond margin, warmth, induration, maceration, callus]; [Drainage amount and character: serous / purulent / sanguineous; odor]; [Tenderness] (Note if absence may reflect neuropathy.); [Abscess signs: fluctuance, crepitus]; [Probe-to-bone result and method if performed]; [Exposed structures: tendon / joint / bone]; [Gangrene: dry / wet; demarcation level]; [Postoperative findings if applicable: incision integrity, dehiscence, suture/staple status, hardware prominence]

Musculoskeletal: [Deformities (Charcot, hammertoes)]; [ROM limitations]; [Focal bony tenderness]; [Stability]

Infection Severity Classification

[Uninfected / Mild / Moderate / Severe] – [Supporting features: local signs (erythema extent in cm, purulence, warmth, induration), depth and structures involved (tendon / joint / bone), systemic features (temperature, heart rate, respiratory rate, WBC abnormalities)] (Required when diabetic foot infection is suspected; use IWGDF/IDSA criteria.)

Ulcer classification (optional for complex cases): [SINBAD components] and/or [WIfI components: Wound / Ischemia / foot Infection] (Report individual component scores.)

Assessment

(List problems in order of severity and urgency. Label osteomyelitis as "suspected" unless confirmed by definitive imaging plus bone culture or histology.)

• [Problem 1]: [Working diagnosis] – [Confirmed / Probable / Possible] – [Key supporting evidence and differential if relevant]
• [Problem 2]: [Diagnosis] – [Evidence and relevance]
• [Additional problems as applicable]

Recommendations

(Numbered problem-based plan. Clearly indicate responsibility: Podiatry vs Primary team vs Other consultants.)

1. Infection management:
   • Cultures: [Specimen plan – prioritize deep tissue or bone over superficial swab]
   • Antibiotics: [Empiric regimen, dose, route with rationale (severity, prior antibiotics, renal function, allergies)] (Recommend only if wound is clinically infected.)
   • Source control: [Bedside I&D / Urgent OR / Staged debridement with timing]
2. Suspected osteomyelitis:
   • Diagnostics: [Imaging plan]; [Bone specimen strategy (biopsy or intraoperative culture/histology)]
   • Management: [Surgical vs medical approach with rationale]
3. Vascular/perfusion:
   • [Perfusion adequate / inadequate / uncertain for healing]
   • [Objective testing recommended if not available]
   • [Threshold for vascular surgery involvement]
4. Wound care and offloading:
   • Dressing: [Type and frequency]
   • Offloading: [Heel offloading / CAM boot / Post-op shoe / Total contact cast]
   • Weight-bearing: [NWB / Heel WB / WBAT] with rationale
   • PT/OT: [Consult if needed for mobility or offloading training]
5. Trauma (if applicable):
   • [Injury pattern and management]
   • [Neurovascular monitoring frequency]
   • [Immobilization and weight-bearing status]
   • [Tetanus prophylaxis status]
6. Glycemic control: [Glucose targets and coordination with primary team/endocrinology]
7. Anticoagulation (if procedure planned): [Hold/bridge plan with coordination]

Communication

[Inter-service communication: who was contacted, when, and content of discussion or agreements] (If recommendations left in chart only, note that direct contact is pending.)

Procedures Performed

(Include only if a procedure was performed this encounter.)

• Procedure: [Name]
• Indication: [Reason]
• Consent: [Obtained from whom]
• Anesthesia: [Type and dose]
• Technique: [Brief description]
• Findings: [Extent of necrosis, purulence, depth, exposed structures]
• Hemostasis/Tolerance: [Method and patient response]
• Specimens: [Type and exact source labeling (deep tissue vs bone); sent for Gram stain / culture / histology]
• Post-procedure orders: [Dressing, antibiotics, weight-bearing, monitoring]

Follow-Up

Podiatry follow-up: [Daily inpatient / PRN / Sign-off with return criteria]

Urgent re-contact criteria: [Worsening erythema, hemodynamic changes, spreading necrosis, new neurovascular compromise, uncontrolled pain or fever]

Outpatient follow-up: [Clinic and timeframe if discharge anticipated]

(Do not auto-populate normal pulses, normal sensation, or generic wound descriptors. Do not copy prior wound measurements unless re-measured today. Omit sections that do not apply. If an exam component cannot be performed, document the reason and plan to reassess.)