Perspectives in Circulation Today
Circulator Boot Clinical Treatment Records
In our previous Newsletter, the lack of documentation of the efficacy of current therapies in peripheral vascular medicine was reviewed. Good clinical medicine begins with a complete history and physical examination along with appropriate testing to document the status of the patient and the appropriateness of his/her assigned diagnoses. Such data should be collected in all patients said to have serious ailments, especially if treatments entailing significant risks are entertained. Here are reviewed the information and data
that ideally should be incorporated in the patient record. Such data comprises the backbone of good patient care and lends itself to both observational studies and the more difficult prospective controlled clinical trial. The Circulator Boot Corporation welcomes any physicians that would care to join us in documenting the efficacy of our treatments alone, against or in combination with other therapies.
The text is spaced to allow copies to be utilized in your clinical record and data to be added to the blanks.
Contents
- A. Identification and basic information
- B. Address and Insurance Information
- C. Personal Medical History:
- D. General Review of Symptoms
- E. Arterial Anatomical Detail and Description of Vascular Procedures Done Prior to Boot Therapy
- F. The Physical Examination
- G. Specifics of the Foot and Leg Data
- H. The Vascular Laboratory and Evaluation of the Leg at Risk
A. Identification and basic information
- Date (mm/dd/year):____________________
- Name (First, middle initial, last name):_______________________________________________
- Birthdate( mm/dd/year):______________ Age:________
- Sex (M or F):______
- Height in inches:________ Weight in pounds:________
- BMI=(Wgt/2.2)/(hgtsquaredx0.000645):________
B. Address and Insurance Information
- Street Address:_________________________________________________________________________________________
- Town or Post Office:_____________________________________________________________________________________
- State (2-letter symbol):____ Zip Code:__________
- Home Phone number :____________________ Business Phone: ___________________
- Name of Employer:______________________________________________________________________________________
- Occupation:____________________________________________________________________________________________
- Occupational hazards or impact of job on your health problem:___________________________________________________
______________________________________________________________________________________________________
- Person to be contacted in case of emergency in your care:______________________________________________________
- Medical-legal problem in current illness:______________________________________________________________________
______________________________________________________________________________________________________
- Name of referring physician:_________________________________________________
Specialty of referring physician:______________________________________________
Address of referring physician:_____________________________________________________________________________
- Medical Insurance, address and policy numbers:______________________________________________________________
_____________________________________________________________________________________________________
- Patient Record file number (physician initials and a 3 digit number)
(Example: Dr. Richard S.Browne patient 19=RSB109):________
C. Personal Medical History
- Chief Complaint:________________________________________________________________________________________
_____________________________________________________________________________________________________
- Duration of chief complaint:________________________________________________________________________________
- Past illneses similar to chief complaint:______________________________________________________________________
- Diagnoses offered by your doctor to explain previous similar complaint:____________________________________________
- Name and date of physician consulted prior to presentation now:_________________________________________________
- Diagnoses offered by above physician:______________________________________________________________________
- Tests or procedures done by your last doctor to support his /her opinion:___________________________________________
- Treatments received under direction of above doctor:____________________________________________________________
- Names of physicians, dates, diagnoses, tests, procedures and treatments of physicians seen before the above physician:
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
- Sleep: Bedtime:_________ Rising time:__________ Quality of sleep: _________________
Any interruption of sleep by current illness or restless legs:______________________________________________________
- Exercise habits and limitations: ____________________________________________________________________________
______________________________________________________________________________________________________
- Appetite (good, loss, why…):______________________________________________________________________________
Typical breakfast:________________________________________________________________________________________
Typical lunch:___________________________________________________________________________________________
Typical evening meal:_____________________________________________________________________________________
Snacks:_______________________________________________________________________________________________
Alcohol intake:_________________________________________________________________________________________
Caffeine intake:_________________________________________________________________________________________
- Smoking history:________________________________________________________________________________________
- Intake of aspirin_________________________________________________________________________________________
- Intake of pain relievers:___________________________________________________________________________________
- Intake of vitamins or nutritional supplements:__________________________________________________________________
- Name of currrent medications and reason prescribed:___________________________________________________________
______________________________________________________________________________________________________
- Drug Allergies and kind of untoward response:_________________________________________________________________
______________________________________________________________________________________________________
- Enviromental allergies:___________________________________________________________________________________
- Family history noting age, cause of death, their current health and any history of diabetes, thyroid disease, cancer,
poor circulation, heart attacks or strokes, high blood pressure, leg problems or psychiatric disorder:
Mother:_______________________________________________________________________________________________
Maternal grandfather:____________________________________________________________________________________
Maternal grandmother:___________________________________________________________________________________
Father: _______________________________________________________________________________________________
Paternal grandfather:_____________________________________________________________________________________
Paternal grandmother:____________________________________________________________________________________
Sisters:________________________________________________________________________________________________
______________________________________________________________________________________________________
Brothers:______________________________________________________________________________________________
______________________________________________________________________________________________________
Suspected familial or genetic disorders:(Such as familial malignant hyperthermia associated with general anesthesia)
______________________________________________________________________________________________________
- Surgical History (list date, reason for procedure and complications if any):
Tonsillectomy:__________________________________________________________________________________________
Appendectomy:_________________________________________________________________________________________
Cholecystectomy (gallbladder removal):______________________________________________________________________
Hysterectomy:__________________________________________________________________________________________
Oophorectomy (removal of ovaries):_________________________________________________________________________
Breast Surgery:_________________________________________________________________________________________
Prostate surgery or treatments:_____________________________________________________________________________
Vasectomy:____________________________________________________________________________________________
Vascular reconstruction procedures on legs, carotids, kidneys or heart:____________________________________________
______________________________________________________________________________________________________
Any erectile dysfunction dating from your vascular procedure:____________________________________________________
Other surgical procedures:_________________________________________________________________________________
- Medical Illnesses Requiring Hospitalization (when, where and why):_______________________________________________
______________________________________________________________________________________________________
- Social, marital, mental and sexual history:
Names and dates of marriages:_____________________________________________________________________________
Current support from partner (stressful?, happy?, loving?, supportive in your work/interests?, supportive in your health
problems? ____________________________________________________________________________________________
Satisfactory mutual sex relationships?:______________________________________________________________________
Dates of successful pregnancies:___________________________________________________________________________
Miscarriages/abortions:___________________________________________________________________________________
Cesarian sections: ______________________________________________________________________________________
Unusual pregnancies, number premature pregnancies, other:_____________________________________________________
Names and state of health of natural children: ________________________________________________________________
Names and state of health of adopted children: _______________________________________________________________
D. General Review of Symptoms
- Weight history corrected for body frame as a clue to long term health and nutrition:
Weight age 18 _______ Weight age 25________ Average of weights age 18 & 25:(A)________
Current weight: (B)__________
Estimation of ideal weight for medium frame (Metropolitan Life):110(F) or 120(M) + 4(Height in inches - 60):(C)______
Estimation of ideal body weight for this patient adjusting for frame:(A +C)/2:(D)__________
Relative weight = B/D (>1.1 overweight, >1.2 obese, >1.5 pathologically obese)
Maximum weight as an adult : _______. If significantly above current weight: Reason for weight loss:____________________
______________________________________________________________________________________________________
Least weight as an adult and date:________ If significantly less than (D) above ask for explanation of the low weight:
______________________________________________________________________________________________________
- Head and Brain (Enter "N"o or give brief explanation):
Lightheadedness on change of position:______________________________________________________________________
Dizziness or vertigo (spinning sensation):_____________________________________________________________________
Any relationship to use of gentamicin or other drugs:___________________________________________________________
Fainting spells: _________________________________________________________________________________________
Difficulty to concentrate: __________________________________________________________________________________
Frequent or severe headaches: ____________________________________________________________________________
History of seizures: ______________________________________________________________________________________
Forgetfulness: __________________________________________________________________________________________
- Eyes:
Glasses (date of last prescription and degree to which glasses corrected visual loss):________________________________
______________________________________________________________________________________________________
Double or blurry vision episodic or constant: __________________________________________________________________
Transient loss of vision in one or both eyes and explanation (?TIA): _______________________________________________
Burning or itching of eyes (Dryness? Allergy?):________________________________________________________________
History of cataracts: _____________________________________________________________________________________
History of diabetic eye changes (retinopathy):_________________________________________________________________
- Ears, Nose and Throat (ENT):
Nosebleeds (Frequency and cause?): _______________________________________________________________________
Postnasal drip or sinus problems (Medications?): _____________________________________________________________
History of nasal discharge or infections or suspicion of carrier state for staphylococcus):______________________________
Deafness or tinnitus(relationship to drugs or antibiotics):________________________________________________________
Deafness: __________________________________________ Tinnitus :___________________________________________
Dental plates: _____________________________ History gum or teeth infection:____________________________________
Persistent hoarseness (diagnosis if any):_____________________________________________________________________
Difficulty to swallow (diagnosis if any):_______________________________________________________________________
History of enlarged glands in the neck (Lymph): _______________________________________________________________
History of goiter (diagnosis and therapy): ____________________________________________________________________
- Heart and Lungs:
New York Heart Function Class: ___________________________________________________________________________
(Class I: patients with no limitation of activities; they suffer no symptoms from ordinary activities.)
(Class II: patients with slight, mild limitation of activity; they are comfortable with rest or with mild exertion.)
(Class III: patients with marked limitation of activity; they are comfortable only at rest.)
(Class IV: patients who should be at complete rest, confined to bed or chair; any physical activity brings on discomfort and symptoms occur at rest.)
History of heart trouble (what, when and what treatments if any):_________________________________________________
History of palpitations, irregular heartbeat or treatment for rhythm disturbance:______________________________________
Shortness of breath of weakness in climbing stairs (how many, how fast and why):___________________________________
Shortness of breath lying flat in bed (orthopnea) and number of pillows used:________________________________________
Past diagnosis or history of emphysema, asthma or wheezing: __________________________________________________
Night sweats (change of pajamas?): ________________________________________________________________________
Cough productive of blood or thick mucus: ___________________________________________________________________
Morning coughing spells: _________________________________________________________________________________
Chest pain (Exertional? Diagnosis? Where?): _________________________________________________________________
History of high blood pressure (how high and what medications if not already listed):__________________________________
______________________________________________________________________________________________________
History of swelling of the ankles (Why? Differential diagnosis includes problems of the heart, kidneys, lymph system,
varicose veins and arthritis):_______________________________________________________________________________
- Gastrointestinal:
History of problems with esophagus, stomach or bowels:________________________________________________________
Heartburn? Difficulty to swallow? Indigestion?_________________________________________________________________
Nausea? Vomiting? Belching? Bloating?_____________________________________________________________________
Trouble or intolerance to specific foods:______________________________________________________________________
Abdominal cramps:______________________________________________________________________________________
Abnormal stool consistency (loose, watery or hard and dry):_____________________________________________________
Lumps, strain, or pain in the groin:__________________________________________________________________________
Blood or mucus in the stool (bright red, tarry black?):___________________________________________________________
- Genitourinary:
History of kidney stones? Problems with urine stream, bladder or kidneys? Blood in the urine?_________________________
______________________________________________________________________________________________________
Number of nocturnal urinations: ______________ Spontaneous nocturnal erections:__________________________________
History of infected urine or burning?_________________________________________________________________________
Difficulty starting urine stream? Urinary frequency or urgency?____________________________________________________
Dysfunction, pain, infection or problems with genitals:__________________________________________________________
Unusual vaginal bleeding:_________________________________________________________________________________
- Bone and Joint:
Stiffness or pain in the neck (treatments?):___________________________________________________________________
Recurrent back pain, backaches, swollen joints or painful joints?_________________________________________________
- Neuromuscular history:
Loss of sensation or tingling or weakness in your hands or feet?__________________________________________________
Muscle weakness, cramps, spasms, twitches or tremor?________________________________________________________
- Endocrine and Metabolic
Symptoms of thyroid underactivity (dry skin, brittle nails, hair loss, change in your hair texture or inability to stand cold):
underline appropriate symptom.
Symptoms of thyroid overactivity (heart rhythm disturbance, weight loss, tremor, heat intolerance or history of
goiter/prominent eyes): underline symptoms.
History of elevated blood sugar, low blood sugar or treatment or diet for sugar abnormality:____________________________
______________________________________________________________________________________________________
History of treatment with cortisone-like drugs (why?):___________________________________________________________
History of abnormal cholesterol, triglyceride, calcium, iron or uric acid levels in the blood:____________________________
______________________________________________________________________________________________________
- Skin:
History of tumors, warts, moles:____________________________________________________________________________
History of bedsores, pressure sores:________________________________________________________________________
Boils or fungus infections? :________________________________________________________________________________
Ease of bruising, easy bleeding, red or purple skin spots?_______________________________________________________
History of ease of sunburning, pigmentation, unusual stretch marks:_______________________________________________
E. Arterial Anatomical Detail and Description of Vascular Procedures Done Prior to Boot Therapy
- Saphenous Vein Healthy or Lost due to:
Coronary bypass surgery:_________________________________________________________________________________
Leg bypass surgery:______________________________________________________________________________________
Thrombophlebitis and/or stasis disease:______________________________________________________________________
- Iliac Artery known to be healthy and patent or:
Known occlusive disease on arteriograms: ___________________________________________________________________
History of angioplasty with or without stents:__________________________________________________________________
- Femoral artery known to be healthy or:
Known occlusive disease on arteriograms: ___________________________________________________________________
Angioplasty with or without stents: _________________________________________________________________________
History of femoral-femoral bypass: __________________________________________________________________________
History of brachial-femoral bypass: _________________________________________________________________________
- Deep femoral: History of profundoplasty: _____________________________________________________________________
- Superficial femoral known to be healthy or:
Known occlusive disease on arteriograms:____________________________________________________________________
History of angioplasty with or without stenting:________________________________________________________________
History of endarterectomy: ________________________________________________________________________________
History of embolectomies: ________________________________________________________________________________
History of femoropoplieal bypass: __________________________________________________________________________
History of femorotibial bypass: _____________________________________________________________________________
History of femoral-dorsalis pedis bypass: ____________________________________________________________________
- Popliteal artery known to be healthy or:
History of angioplasty with or without stenting:________________________________________________________________
Known occlusive disease on arteriograms:____________________________________________________________________
- Tibial arteries known to be healthy or:
Known occlusive disease on arteriograms:____________________________________________________________________
Tibial angioplasty with or without stenting:____________________________________________________________________
- History of sympathectomy?________________________________________________________________________________
- History of fibrinolytic therapy?______________________________________________________________________________
- Vascular procedures done during period of boot therapy and your care:____________________________________________
- Vascular procedures done since boot therapy and study terminated:______________________________________________
F. The Physical Examination
- Body size: Weight: ____________________ Height: ____________________
- Vital Signs:
Temperature (designate oral or rectal):________
Respiratory rate: _________
Pulse rate:________
Blood pressures: Right arm sitting: _____ Left arm sitting:______
Standing BP in highest arm:_________ Supine Blood pressure in highest arm:SBP ______
(A fall of 30 mm Hg between supine and standing compatible with significant diabetic neuropathy and/or, if accompanied by a rise in pulse rate, low blood volume or excessive medications.) - Ankle systolic blood pressures and Ankle-Brachial Indices:
BP right ankle supine: RAS _____ BP left ankle supine: LAS_____ ABI right ankle: RAS/SBP or _____ ABI left ankle: LAS/SBP or _____ - Classification of Pulses by Palpation:
Pulses of Patient by Palpation: (0) meaning not palpable Femoral*:Left________; right________ (D) meaning present by Doppler only Radial*:Left________; right________ (trace) meaning faint but likely there Popliteal: Left________; Right________ (1+) meaning definite but requires care to find Posterior tibial: Left________; Right________ (2+) meaning easy to find with firm touch Dorsalis pedis: Left________; Right________ (3+) meaning easy to find with light touch Carotid: Left________; Right________ (4+) meaning visible pulsation Preauricular: Left________; Right________ * Note if synchronous (delay could signify coarctation of the aorta) - Vascular bruits:
Carotids Flanks Groin Popliteal Area Left _____________ _____________ _____________ _____________ Right _____________ _____________ _____________ _____________ - Head and Neck exam:
Male pattern balding ______________________________ Diffuse loss scalp hair____________________________________
Thinning or loss eyebrows/eyelashes _______________________________________________________________________
Subcutaneous scalp lumps or bony prominences:_____________________________________________________________
Dandruff or unkempt scalp: _______________________________________________________________________________
(Poor hygiene may mean patient unable to follow medical program or care for skin lesions) Keratotic lesions or possible basal cell lesions on scalp, ears or face______________________________________________
Hearing aid or inability to hear whisper or fingers rubbed together at elbow length?___________________________________
Dirty ears, draining ears or excessive wax in the ears? (Dry crumbling was may indicate hypothyroidism):________________
Loss of conjugate gaze? Oculomotor palsy?__________________________________________________________________
Pupils respond to light and accomodation equally?_____________________________________________________________
(Diabetic oculomotor neuropathy spares the pupil while tumor or aneurysm do not.) Nystagmus?____________________________________________________________________________________________
Cloudy cornea or ocular lens?______________________________________________________________________________
Retinal abnormalities (Lipemia retinalis? Diabetic retinopathy [microaneuryms, punctate hemorrhages, hard exudates, cotton
wool or soft exudates, venous dilatation, venous beading, neovascularization or retinal detachment])_____________________
______________________________________________________________________________________________________
Increased cupping of the disk? Firm eye? (history of glaucoma?)_________________________________________________
Visual acuity on eye chart (20:20, 20:400 whatever): Left eye_____________________ Right eye______________________
Facial telangiectasia and/or rhinophyma (Suggestive of alcoholism)_______________________________________________
Prominent facial wrinkling and high color (Outdoor living vs cigarette addiction and reactive polycythemia)________________
Tenderness over maxillary and/or frontal sinuses:_____________________________________________________________
Deviated nasal septum___________________________________________________________________________________
Pale swollen nasal mucosa (Nasal allergy?)__________________________________________________________________
Unusual dental caries, gum retraction or peridontitis? Tender on palpation?_____________________(Related to facial pain?)
Cervical or supraclavicular adenopathy?_____________________________________________________________________
Unusual cervical lordosis? (Cervical lordosis and/or lumbar lordosis commonly associated with hypertrophic arthritis
of the spine and pseudoclaudication of the legs.)______________________________________________________________
______________________________________________________________________________________________________
Trachea deviated to one side? (Consider tension pneumothorax, atelectasis etc):____________________________________
Thyroid size and consistency? (Normally each lobe is about the size of the distal phalanx of the thumb and the consistency
about that of a partially flexed bicep):_______________________________________________________________________
______________________________________________________________________________________________________ - Examination of the Chest, Heart and Lungs:
Shape of the thorax (Pectus excavatum? Barrel-shape etc)_____________________________________________________
Breast lumps, galactorhea, or axillary adenopathy?____________________________________________________________
Cyanosis of lips or fingertips? Clubbing?_____________________________________________________________________
Unusual respiratory effort? Rib retraction? Use of accessory muscles (abdominal or sternomastoids)?___________________
Respiratory rate and pattern? Cheyne-Stoke? Periodic breathing?_________________________________________________
Prolonged expiratory phase? Wheezes? Crackles? Rhonchi?___________________________________________________
Tenderness over the sternum (hyperplstic marrow?) or costochrondral joints(Tietze's syndrome?)_______________________
Tactile fremitus? (Increased fremitus is seen with fluid in the lungs and decreased with COPD):________________________
Whispered Pectoriloquy? (Patient whispers 99 which should not be heard or heard faintly over the chest. A clear 99 may
mean fluid in the chest)__________________________________________________________________________________
Increased bronchophony? (A localized loud 99 may mean fluid in the lung or a consolidation) _________________________
Estimation of 1 second vital capacity: the match test (Can the patient blow out a match with a widely open mouth? Patients
with COPD cannot do it without pursing their lips.)____________________________________________________________
Pulse rate and pattern (regular, regular with a few pauses, regular with a few premature beats or totally irregular)?
________________________________________________________________________________________________________
Neck veins (Visible, distended or flapping? Is there a hepatojugular reflux? (Increased central venous pressure [high veins]
and tricuspid insufficiency [obvious pulsations] are considerations.)______________________________________________
Palpation of the precordium and the point of maximum impulse [PMI] (Normally the size of a penny and located about the
midclavicular line...A forciful more sustained PMI shifted laterally may be seen with hypertension, aortic stenosis and
insufficiency and mitral regurgitation:________________________________________________________________________
______________________________________________________________________________________________________________
Heart murmurs? (Heart murmurs radiating to the neck are loudest in the low neck while carotid bruits are commonly softer in
the low neck and louder higher)_____________________________________________________________________________
______________________________________________________________________________________________________________
Gallops? (An S3 gallop is associated with LV failure and is caused by the atrial volume slamming into an already partly filled
ventricle. The S4 gallop is pre-systolic in timing and is commonly associated blood trying to enter a stiff non-compliant
ventricle during atrial systole)______________________________________________________________________________
________________________________________________________________________________________________________________ - Examination of the Abdomen and Groin:
Abdominal shape (flat, scaphoid, or protuberant)?_____________________________________________________________
Tenderness to percussion over the kidneys or liver?___________________________________________________________
Palpable organs, masses or pulsations? ____________________________________________________________________
Distention or tympany? (A distended stomach pressed up against the diaphragm will transmit loud heart sounds to the
epigastrium.)____________________________________________________________________________________________
Bowel sounds (increased or decreased?)_____________________________________________________________________
Abdominal visible varices or liver palms?_____________________________________________________________________
Diastasis recti, inguinal or femoral hernias or inguinal adenopathy?________________________________________________
_________________________________________________________________________________________________________________
Rectal examination (hemorrhoids, anal skin tags, poor rectal tone or a prostatic mass) _______________________________
_______________________________________________________________________________________________________________ - Examination of the Skin of the Diabetic Patient:
Traumatic and surgical scars due to what and when: ___________________________________________________________
Dryness, flaking and cracking (especially of feet): _____________________________________________________________
Neurodermatitis? Tinea pedis? Tinea cruris? Candidiasis? Uncontrolled acne? Boils? Fununcles? (Uncontrolled diabetes is associated with them all):_________________________________________________________________________________
_____________________________________________________________________________________________________________________
Diabetic dermopathy? (multiple 5-12 mm coin-sized, discrete, dull-red macules and papules ---acute lesion may be vesicular
--- especially found on the extensor surfaces of the extremities__________________________________________________
Necrobiosis lipoidica diabeticorum? (especially on the shin but occur on face, arms and trunk…red-brown-yellowish plaques
4-8 lesions common ... one third complicated by multiple painful ulcers) May be helped by boot therapy:_________________
__________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
Yellowing of the skin suggestive of carotenosis? (especially palms and soles): ______________________________________
Xanthoma diabeticorum? (yellow frequently erythematous papules or nodules in sudden crops on trunk, buttocks, elbows,
palms or soles associated with uncontrolled diabetes and hyperlipidemia and may disappear with control of the diabetes and
hyperlipidemia._______________________________________________________________________________________________________
______________________________________________________________________________________________________________________ - Examination of the Ischemic or Neuropathic Limb:
Determine category of acute ischemia if present:_________________________________________________________________Classification of Acute Ischemia Findings Category I Category IIa Category IIb Category III Sensory loss None Minimal Yes Profound Muscle weakness No No Yes Profound Rest Pain No Yes Yes Yes Arterial Doppler Yes No No No Venous Doppler Yes Yes Yes No Significance: Urgency No Yes Yes Yes Reversibility Yes Yes Yes No Viability Yes Yes Yes No J Vasc Surg 26:517-38, 1997 Determine Wagner Class of foot lesions and describe locations:
(0) if intact skin {may have bony deformities}__________________________________________________________________
(1) if localized superficial ulcer______________________________________________________________________________
(2) if deep ulcer to tendon, bone, ligament or joint_____________________________________________________________
(3) if deep abscess or osteomyelitis_________________________________________________________________________
(4) gangrene of toes or forefoot_____________________________________________________________________________
(5) gangrene of whole foot_________________________________________________________________________________
Rubor on dependency and blanching on elevation? Include degree of rubor, height at which blanching occurs, time required
for color to return after lowering foot (normal 10 sec) and time taken for a superficial vein to fill (normal 15 sec).
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
Red or blue areas that do not blanch on elevation or direct pressure? Any confluent petechiae? (Such areas are likely to
breakdown and slow the healing/cure process_________________________________________________________________
Mottling, coldness, blistering (in absence of edema)?___________________________________________________________Grade the strength/briskness of the deep tendon reflexes:
(0) if absent Left Right (+/-) if requires reinforcement Achilles _____________________ _____________________ 1+ if present but weak Patellar _____________________ _____________________ 2+ if present and easily elicited Radial _____________________ _____________________ 3+ if prominent Biceps _____________________ _____________________ 4+ if prominent and clonus elicited Triceps _____________________ _____________________ Deep pain sensation (Squeeze the Achilles tendon)____________________________________________________________
Light touch sensation (ability to feel a cotton swab)____________________________________________________________
Position sensation (can say correctly if toes pushed up or down__________________________________________________
Loss of mass of the extensor digitorum brevis muscle (elicited by dorsiflexing the toes against resistance) _______________
_________________________________________________________________________________________________________
Loss of Sudomotor function (no sweat, dry foot)_______________________________________________________________
Hammar toes and loss of intrinsic muscle mass of foot_________________________________________________________
Other foot deformity ______________________________________________________________________________________
Vibration sense (tuning fork or other at patella, internal malleolus and 1st metatarsal head_____________________________
Temperature sensation (tube containing hot water vs a tube containing cold water)___________________________________
Semmes-Weinstein 5.07 (10 gm) filament under the big toe, the 1st metatarsal head.the 5th metatarsal head and the heel
_____________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________ - Diagnoses based on physical examination:___________________________________________________________________
______________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________
G. Specifics of the Foot and Leg Data
- Walking Limitations: Claudication, Angina or Congestive Heart Failure:
Walking limitation due to bad leg(s), heart failure or angina is best determined on a treadmill, the examiner walking with the patient in a hallway
and, least desirable by the history given by the patient or family. Categorize the limitation into one of the groups in the left column below:
Category Baseline One Month Two months End of Data L Leg R Leg Angina L Leg R Leg Angina L Leg R Leg Angina L Leg R Leg Angina Rest pain _____ _____ _____ _____ _____ __________ _____ _____ _____ _____ _____ _____ 1 step or less _____ _____ _____ _____ _____ __________ _____ _____ _____ _____ _____ _____ 10 steps or less _____ _____ _____ _____ _____ __________ _____ _____ _____ _____ _____ _____ 11-50 steps _____ _____ _____ _____ _____ __________ _____ _____ _____ _____ _____ _____ 51-100 steps _____ _____ _____ _____ _____ __________ _____ _____ _____ _____ _____ _____ 1/2 to 1 block _____ _____ _____ _____ _____ __________ _____ _____ _____ _____ _____ _____ 1-2 blocks _____ _____ _____ _____ _____ __________ _____ _____ _____ _____ _____ _____ 2-5 blocks _____ _____ _____ _____ _____ __________ _____ _____ _____ _____ _____ _____ 5-10 blocks _____ _____ _____ _____ _____ __________ _____ _____ _____ _____ _____ _____ Occas pain on hills _____ _____ _____ _____ _____ __________ _____ _____ _____ _____ _____ _____ - Debridements:Sharp Debridements are commonly done. Alternative techniques include (1) maggot therapy; (2) Ultrasound; (3) the "Vac",
(4) Pumping the lesions in Sea Soaks containing antibiotics. List debridements done before, during and after boot therapy or the treatments
the patient received under your care:
Before presentation (elsewhere):___________________________________________________________________________
During this study:_______________________________________________________________________________________
After study accomplished_________________________________________________________________________________ - Risks for amputation: If patient advised to have an amputation prior to boot therapy, choose among the following the circumstances that best
describe why:_____
(1) Patient request because of intractable pain.
(2) Sepsis persisting in spite of aggressive attempts to control it (the part to be amputated thought to be the
source of the sepsis).
(3) Mummification of part to be amputated with no hope for a useful foot even if an effective revascularization
procedure was or could be accomplished.
(4) A useless remnant … a dead portion of the limb that would be of no conceivable use to the patient even if it
could be largely healed.
(5) Physician's judgment that healing unlikely.
(6) Persisting osteomyelitis
(7) Vascular tests suggesting that healing unlikely - Actual amputations:
Amputations on either leg prior to your treatment (when and where and why (above choices)___________________________
Major amputations urged on patient prior to your treatment (why)_________________________________________________
Major amputations advised as likely necessary prior to your treatment (why)________________________________________
Minor amputations urged on this patient prior to your treatment (why)_____________________________________________
Minor amputations advised as likely necessary prior to your treatment (why)________________________________________
Amputations done on either leg during your treatment once patient admittted to treatment in hopes of effecting benefit
_______________________________________________________________________________________________________
Amputations done on treated leg after your treatment once patient discharged having had maximum benefit of boot therapy:
_______________________________________________________________________________________________________ - Mortality Data:
Death during study, cause and any relationship to treatments____________________________________________________
Death after study, how soon after, cause and any relationship to treatments________________________________________ - Wagner classification of foot lesions (See Physical Examination)_________________________________________________
- University of Texas Wound Classification System
"amp" (minor amputation) and "Mamp" (Major amputation) represent their amputation experience:
Stage Grade "0" Grade "1" Grade "2" Grade "3" A # 164 46% Pre- or post-ulcerative lesion, completely epithelized 0 amp Superficial wound not involving tendon, capsule or bone 0 amp Wound penetrating to tendon or capsule 0 amp Wound penetrating to bone or joint 0 amp B # 158 44% Stage "A" and Infection 12.5%amp Stage "A" and Infection 8.5%amp Stage "A" and Infection 28.6%amp 3.3%Mamp Stage "A" and Infection 92%ampr 13%Mamp C # 21 6% Stage "A" and Ischemia 25.0%amp Stage "A" and Ischemia 20.0%amp Stage "A" and Ischemia 25.0amp 25.0%Mamp Stage "A" and Ischemia 100%amp 33%Mamp C # 21 6% Stage "A" and Infection and Ischemia 50%amp Stage "A" and Infection and Ischemia 50%amp 50%Mamp Stage "A" and Infection and Ischemia 100amp 100%Mamp Stage "A" and Infection and Ischemia 100%amp 91%Mamp
Class of left foot : __________________________ Class of right foot: __________________________________ - Documentation of lesions:
Numbers and Size of Breakdown areas on legs/feet on presentation:Number of Lesions Sum of the areas of lesions Left foot/leg _________ ______________________________ Right foot/leg _________ ______________________________ Number of Lesions Sum of the areas of lesions Left foot/leg _________ ______________________________ Right foot/leg _________ ______________________________ Numbers and Size of Breakdown areas on legs/feet after two months of treatments:
Number of Lesions Sum of the areas of lesions Left foot/leg _________ ______________________________ Right foot/leg _________ ______________________________ Numbers and Size of Breakdown areas on legs/feet after three months of treatments:
Number of Lesions Sum of the areas of lesions Left foot/leg _________ ______________________________ Right foot/leg _________ ______________________________ Numbers and Size of Breakdown areas on legs/feet at end of treatments:
Number of Lesions Sum of the areas of lesions Left foot/leg _________ ______________________________ Right foot/leg _________ ______________________________ Numbers and Size of areas of non-blanching rubor on legs/feet on presentation:
Number of Lesions Sum of the areas of lesions Left foot/leg _________ ______________________________ Right foot/leg _________ ______________________________
Areas of mummification: Identify which toes by entering T1 for 1st toe, T2 for 2nd toe… etc. List portion of toe mummified in
parentheses: (1) meaning all of the toe, (1/2) meaning half of the toe etc.. Thus T2(1/2) means half of 2nd toe, T3-5(1,1,1/2)
means all of toes 3 &4 and half of toe 5. Specify if more of foot mummified.
On presentation One Month Two Months Three Months End of Rx Right leg/foot _________ _________ _________ _________ _________ Left leg/foot _________ _________ _________ _________ _________ - Osteomyelitis
Bones involved:__________________________________________________________________________________________
Diagnosis confirmation by:Serial Plain x-rays______________ MRI______________Probe to bone______________ Technetium scans______________ Indium 111 WBC scan______________ Bone biopsy______________
On presentation: _______ 2 weeks _______ 1 month ______ 2 months _______ End of Rx______ Culture data:
Pathogens isolated:______________________________________________________________________________________
Resistant organisms cultured:_____________________________________________________________________________
White counts: Highest 1st few days of Rx_______ One month ______ Two months _______ End of Rx __________
Fever: Enter the highest temperature measured on day 1: ______- Date discharged from active treatment to follow-up status: __________________________
- Outcomes of foot/leg problems: Choose the letter that best describes the patient outcome: ___________
(A) Foot/leg cured, intact and fully functional.
(B) Presenting dead elements of foot gone and remnant cured and fully functional.
(C) Presenting problem improved but persists, foot/leg stable and patient getting along & satisfied.
(D) Presenting problem continued to worsen in spite of aggressive therapy deemed adequate by boot consultants and other therapy
or amputations necessitated.
(E) Improving but lost to therapy because of finances, advice of other physicians or noncompliance
(F) Stable or slightly worse but lost to therapy early in therapy because of finances, advice of other physicians or noncompliance.Outcome details (if above did not adequately describe outcome):_________________________________________________
_______________________________________________________________________________________________________Long Term Follow-up: New Lesions and/or relapse at previous site:
Date and site of new lesions _______________________________________________________________________________
Date of breakdown at site of previously treated lesion(s)_________________________________________________________- Effect of Boot treatments on the retina, kidneys and heart:
Long Boot Therapy may have beneficial effects in the diabetic on retinal, renal and heart disease. These problems may
obviously affect the outcome of leg problems and deserve attention on that basis. In the next few questions, you may
document changes in this area that may help explain the mechanism of action of boot therapy and help us provide data to
show that boot therapy may restore vision, keep patients off of dialysis, relieve angina, decrease need for hospitalization
for congestive heart failure and, thus, significantly improve the quality of life.
Patients with decreased visual acuity due to retinal disease (not cataracts):
Baseline visual acuity _________ Acuity at 1 month_________ Acuity at end of Rx_________ Retinal hemorrhages at baseline_________ Retinal hemorrhages at 1 month_________ Retinal hemorrhages at end of Rx_________ Retinal exudates at baseline_________ Retinal exudates at 1 month_________ Retinal exudates at end of Rx_________ Patients with azotemia possibly considered for dialysis:
Many diabetic foot patients have swelling of their legs possibly related to low albumen levels and the nephrotic syndrome,
mild heart failure or stasis and prolonged dependency of their feet. Such patients are commonly given potent diuretics
which may contract volume and worsen any azotemia they may have. Long Boot therapy may increase their cardiac output
and increase the effectiveness of their diuretics resulting in a further increase in azotemia. The azotemia in such patients
can be significantly reduced by decreasing the diuretics and ensuring an adequate fluid intake. For the patients you describe
below, enter their BUN, creatinine and note any use of diuretics.Serum creatinine BUN Dosage/use of diuretics Baseline/prior to boot therapy ________ ______ _____________________________ 1 wk after daily Long Boot Rx ________ ______ _____________________________ 1 month after start Long Boot ________ ______ _____________________________ End of Boot therapy ________ ______ _____________________________ Diagnosis of kidney problem:_______________________________________________________________________________
Number of Long Boot treatments patient had by the end of his program and average number/week:______________________
Did/does the patient have a history of kidney damage due to antibiotics or contast media?_____________________________New York Heart Classification (NYHC), a functional and therapeutic classification for the prescription of physical activity in
cardiac patients:
Class I: No limit to actiivities. They suffer no symptoms from ordinary activities.
Class II: Slight limitation of activity, comfortable at rest or with mild exertion.
Class III: Marked limitation of activity. Comfortable only at rest.
Class IV: Patients who should be at absolute bedrest or confined to bed or chair. Any physical activity
brings on discomfort and symptoms occur at rest.
Baseline NYHC _____ NYHC after 1 month Long Boot _____ NYHC after 2 months Rx _____ NYHC end of Rx _____ - Osteomyelitis
H. The Vascular Laboratory and Evaluation of the Leg at Risk
- Blood pressures and ABI's:
Baseline:
Right arm sitting Left arm sitting Standing BP in highest arm Supine BP in highest arm:SBP ____________ ____________ ____________ ____________ Systolic Blood Pressures and ABI's:
Supine Brachial BP Right ankle BP Right ABI Left ankle BP Left ABI Baseline __________ __________ __________ __________ __________ One month __________ __________ __________ __________ __________ Two months __________ __________ __________ __________ __________ End of boot Rx __________ __________ __________ __________ __________ - Classification of Pulses by Palpation:
Pulses of Patient by Palpation: (0) meaning not palpable Femoral*:Left________; right________ (D) meaning present by Doppler only Radial*:Left________; right________ (trace) meaning faint but likely there Popliteal: Left________; Right________ (1+) meaning definite but requires care to find Posterior tibial: Left________; Right________ (2+) meaning easy to find with firm touch Dorsalis pedis: Left________; Right________ (3+) meaning easy to find with light touch Carotid: Left________; Right________ (4+) meaning visible pulsation Preauricular: Left________; Right________ * Note if synchronous (delay could signify coarctation of the aorta) - Vascular bruits:
Carotids Flanks Groin Popliteal Area Left _____________ _____________ _____________ _____________ Right _____________ _____________ _____________ _____________ Many vascular tests are available. Here the "Pole test", transcutaneous oxygen levels both on room air and on 100%
oxygen, and toe blood pressures were chosen as quick, economical and reliable guides to healing potential. Other
tests may be entered under the "Other" category. In the Pole, a means of detecting cutaneous flow in the distal foot
(such as a PPG probe, Laser Doppler etc) is utilized. With the patient in the supine position, the foot is raised
above the examining table and the height at which cutaneous flow ceases (if it does cease) is measured. Thirty
inches of water pressure corresponds to 55 mm HG. The technique provides a guide to true perfusion pressure in
patients with medial calcinosis of their tibial arteries and pseudohypertension at the ankle level. - Summary of Chosen Vascular Tests:
Time of Test Pole Test TcPO2 room air TcPO2 100% O2 Toe blood pressure Right foot Left foot Right foot Left foot Right foot Left foot Right foot Right foot Baseline _______ _______ _______ _______ _______ _______ _______ _______ One Week _______ _______ _______ _______ _______ _______ _______ _______ One month _______ _______ _______ _______ _______ _______ _______ _______ Two months _______ _______ _______ _______ _______ _______ _______ _______ End of Boot Rx _______ _______ _______ _______ _______ _______ _______ _______ - Summary of Results of Other Tests Performed:
Name of Tests and Results:
Baseline: _________________________________________________________________________________ One week: _________________________________________________________________________________ One month: _________________________________________________________________________________ Two months: _________________________________________________________________________________ End of Boot treatments_________________________________________________________________________________