Help In G.P Letter writing

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Can someone please help me!!
I have been seeing a client for the past 7 months who is a diabetic.
When I first saw him in March 2013, he was complaining of hot feet at night, and pain when the bed sheets were on him. My patient does have slight O/M, so I gave him some Imperial Mycosis to pop on all over his nails and feet in the hope of some positive progress in the coming months of me seeing him.
I see him every 6 weeks, and on some visits he said he found an improvement in the hot feet scenario, so I asked him to continue with the Imperial Mycosis to treat the nails. I thought I cracked it!!
I saw him today, and he is complaining again of hot feet, and numbness on his right pad. His feet are very warm to touch, but he said he could not feel me touching him.
I now suspect Peripheral Neuropathy??
What do I do next?
Do I write to his GP, if so what do I put in the letter as I have never written to a GP before, and I don't want to sound too dumb!! Or do I just keep on treating as normal, but keep an eye for any developing ulcers or anything suspicious?

 

Hi,

Write to the GP and tell him of your findings. Tell the patient you are doing so. Keep your letter polite and to the point. And don't expect a reply.

Ideally patients with diabetes are best seen and treated within the NHS. You certainly don't want to be waiting until an ulcer develops. I know some NHS treatment is poor, but it won't get any better by private chiropodists/podiatrists covering up any possible lack of available care.

Refer the patient to the GP. Offer to see the patient if the GP cannot accommodate him.
You should really have established referral pathways for your at-risk patients. It means a little work for you, but well worth it for those problem patients who need rapid access to NHS services.

From your post I believe you are not fully up to speed on diabetes care. Check with your professional body for available diabetes care CPD.

 

Hi,

The symptoms described sound like possible neuropathic pain - however this would need to be confirmed by a specialist.

You need to write to the GP advising him of what you have found so he can a) review the patients diabetic control and modify their anti-diabetic medication if required b) prescribe appropriate medication for the neuropathic pain if required and c) refer the pt on to the NHS to be monitored by a specialist diabetic MDT. If the patient has diabetic neuropathy they really need to be monitored by a specialist diabetic foot team in an aim to prevent ulceration from occurring. Please do not wait until the patient has ulcerated before you write to the GP. Research has shown that once a patient has had a diabetic foot ulcer, recurrence rates of re-ulceration are up to 41% within 3 years and 70% within 5 years and amputations are preceded by foot ulcers in 85% cases - therefore prevention of ulceration is paramount.

I hope this helps.

 

Remember, that as a podiatrist you are there to provide advice, treatment and education on all foot pathologies. Part of that means knowing when to refer on and to whom.

I disagree that a neuropathy diagnosis requires a specialist. Basic tests done by a podiatrist/GP/nurse will give you this information, specialist intervention is only necessary if the tests indicate vascular/ neuro insufficiency. Depending on the level of insufficiency the patient should be seen in either the NHS on a regular basis for foot care, or a Foot Protection Team.

If you have a diabetic patient you should really be asking what their control is like. Get into the habit of asking what their last HbA1C was; what their last reading was; how do they feel generally; when was their last foot screen ( this should be done annually); when were their eyes tested (again, this should be done annually). You should also be doing some basic vascular and neuro tests, which you should include in your letter to the GP. As a healthcare professional the GP will want more than 'hot feet' as a basis for referral. Basic tests should include.

Temperature gradient
Capillary refill
Pulses
Muscle strength
Sharp blunt (dermatones)
10g monofilament (dermatones)
Vibration perception
Skin appearance
Hair growth

I agree 100% with the other posters when they say that you should not wait for an ulcer to develop. NO WAY! Your role is to PREVENT ulceration. I also agree that from your post it does appear that you do need to brush up on your diabetes care. Please do check out a CPD course and have a read of some of the guidelines on diabetic care, for example NICE guidelines. I would do this not only for your future patients, but also for yourself to prevent problems/litigation in the future

Oh and remember, onychmycosis is more common in those with diabetes than without.

 

Would a doppler be beneficial to me? If so, can you recommend one as well as probe sizes as I see they range from 8mhz down to 2?

 

KDfootsteps,

PLEASE PLEASE GET YOURSELF ON A DIABETES COURSE!! What benefit would a Doppler be to you at this stage in your career if you are unable to perform basic vascular tests and interpret the findings? You don't need a Doppler. If you do use one you must make sure that you are able to use it effectively, for example, you would need to know the difference between mono/bi/triphasic sounds and their implications. If you have minimal diabetes knowledge then you may misinterpret healthy warm skin with a bounding pulse as a good sign, however, this is an indicator of autonomic neuropathy, so again, as has been said earlier, a good knowledge of diabetes is ESSENTIAL.

My advice would be for you to save your money on the Doppler and spend it on a diabetes course. Just get to grips with the basic questioning, neuro and vascular tests and then refer on if you feel further investigation is necessary (Doppler/ABPI's etc). I personally would not touch those with diabetic complications privately (unless you are part of a private hospital or you have worked as a high risk podiatrist). These people are looked after very well in the NHS by specialist teams.

If your patient is diabetic but does not yet have complications, by all means, continue to treat them, and document EVERYTHING. Just get into the habit of regular testing, and when necessary refer on. Leave those with complications to the specialist teams. Remember, diabetics are a HIGH RISK group. If you don't have the required knowledge to treat them you are putting yourself at HIGH RISK!!!

 

Thank you for all of your guidance. I only have 2 patients that are diabetics, so I slacked quite a lot on the cpd courses. I guess I'll have to not be so stingy and book one up!!!
I unfortunately trained at the west midlands school and their training for diabetes was virtually non existant. All they said about it was to check the patients pedal pulses. Which I do. I qualified, left the clinic and was on my own. No back up support was provided although it was offered, but they never got back to you. I've only been doing basic cpd lessons since!!
Fool I hear you say, well yes, I am proving it to myself right now.
At least I did ask you guys for help instead of ignoring the issue, so I'm heading in the right direction.
Regards

 

I don't think you're a fool you asked a question, and the answers allowed you to see the holes in your practice when treating this patient group. If you continued to treat these people, knowing you were I'll equipped to do so - then yes, that would be pretty foolish!! I'm glad you are going to attend a CPD course in this area, and definitely have a look at the NICE guidelines on diabetes care, there is a whole section on the foot. The lower link has a useful care pathway that may provide further insight.

http://www.nice.org.uk/nicemedia/live/10934/29242/29242.pdf

http://www.diabetes.org.uk/Documents/Professionals/Education and skills/Footcare-pathway.0212.pdf


Good luck

 

Unfortunate indeed! You are to be commended for asking the question and you have some excellent advice from colleagues here. Find out your local MDT and make contact with them and establish a fast track pathway for your patients. Specialist podiatric diabetic management is not the kind of thing you can competently do following a CPD course - don't let anyone tell you otherwise. Ask the diabetic team if you can shadow them for a clinical session and you will understand why. Learn the basics well and establish referral pathways. Learn as much as you can on care and management of the diabetic and high risk foot in clinical practice. And keep asking questions.

Mark

 

Hello kdfootsteps,

These links will provide you with plent of information on Diabetes and CPD opportunities, workshops/seminars etc.

http://www.footindiabetes.org/

http://www.diabeticfootjournal.co.uk/

http://www.diabetesonthenet.com/events/fduk/2013-11-12-2218

Good luck

Podess

 

You quote as being trained with West midlands school and that you did very little diabetic care.

That however is no excuse, we know that kind of training is basic but that's no excuse not to further your training. if you are aware you lack experience with diabeties, then get it, do what has been suggested by the other posters.

you suggested back up was offered , so why didn't you follow it up, ? its your business, your life and your patients, so its up to you to follow up further training.

asking on a public forum, whilst at least shows some insight ,is not the answer.

if it were that easy no one would go on any courses.

I also attended a shortened course, but in the last 20 years have attended at least 6 major courses , and exams plus regular updates. this on top of 3 years nursing training and 1 years midwifery, totalling 20 years in a hospital environment.

I really do wonder if this is a genuine question , or is it a troll?????

 

Wow, I'd hate to be your enemy!!

I have furthered my training on other things. Like I said, I only have 2 diabetic patients, so my time with them is minimal. I haven't wanted to further my diabetic education!!
Since posting, I have had some wonderful response from some caring people who could/have put me on the right track. I don't see any help or direction coming from you, only critism!!
Please remember that yes it is my business and I will do what training is required of me in relation to the majority of my patients needs. If I come across something not known, I will ask for help and I have asked!! I have even contacted the school, but if you can read my postings correctly, you will see that I've had no joy with them.
I'm glad for you having all your medical knowledge of 20 years, and I'm sure in that time you didn't know an answer to something so you asked for help!! After all we are only mere humans! !
The question I asked was genuine and the only troll on here is you!!
If you can't help, then don't bully!!

 

In Australia we have a programme that is funded by Medicare (NHS equivalent?) that allows anyone with a chronic disease eg Diabetes, to receive 5 consultations with appropriate allied health professionals for their condition.
This might mean a diabetic will see a diabetic educator once, a dietician twice and podiatrist three times for care in a year or they may have all 5 consults with a podiatrist instead. Any further appointments must be paid for out of their pocket.
The good thing is a letter must be written to the G.P. for the first and last appointment informing him/her of your treatment and evaluation. I usually send photos as well especially if there are ulcers. This way the doctor has all the relevant info from the allied health professionals to make further decisions regarding the patients care. It certainly trains you up in the letter writing department!
I try to keep the letters brief and to the point. No more than 1page (if I can) as doctors are very busy and have informed me they really only want necessary information. I have made up a document that allows me to 'tick' boxes regarding neurological, circulation and muscular tests that I can attach to the letter if the Doctor requires more info that won't take long to read.
Hope this helps

 

Do I write to his GP, if so what do I put in the letter as I have never written to a GP before, and I don't want to sound too dumb!! Or do I just keep on treating as normal, but keep an eye for any developing ulcers or anything suspicious?

The quality and quantitiy of your communication with fellow professionals is vitally important to maximise and ensure your standard of patient care.

The standard letter to another health professional usually consists of four elements.
1. Introduction (name, sex, age, occupation, relevant social history of patient and a short a outline of your reason for contacting them, eg 'a marked reduction in sensitivity of the plantar aspect' or 'chronic probable mycotic infection of nails and skin of feet', etc, etc
2. Summary of relevant subjective symptoms (what the patient complains of, sometimes using the patient's words).
2. Summary of relevant objective symptoms ( the results of your tests and examinations).
3. Give them your considered view of possible diagnosis (if relevant) and tell them what you would like them to do. All with as much tact as it takes to get the best outcome for your patient.

Remember to put a copy of the letter in the patient's records.


Bill

 

i think your patient certainly needs some intervention. it is obvious that the patient is uncomfortable and that you are concerned, hence your post on this site.
i agree with the views of the previous post referral to a diabetic foot care team would be the most appropiate action.
re your letter, keep it simple
chief complaint, signs and symptoms, duration
relevant history
past treatment and outcome
perhaps suggest follow up at high risk foot clinic.

your client may need a full assessment as to their diabetic control, endocrinologist, risk factors, vascular review, etc

get permission from your patient to do so first please.
the patient will be appreciative that you have taken an interest and take their symptoms seriously.

 

Actually, a good critique is one of the most helpful things you can have. It is not bullying. On the other hand, if your patient develops a neuropathic foot ulceration that becomes refractory and requires a BK amputation and you didn't assess the deteriorating limb condition and referred the patient on appropriately, you may very well find yourself accused in case of negligence during which you may face a prosecuting barrister, whose questions and observations are likely to be much more incisive and critical than those posed by Pauline. It isn't a game. For many people with diabetic foot syndrome who might seek your professional advice and help, it could mean the difference between having a healthy limb or none at all. Ot life or death.

Good luck!

 

Wrt the diabetic foot, write to the GP if concerned, and keep a copy of the referral letter in the patient notes. Give the patient written advice and document that in the notes. If a patient still has not been seen by another health professional, contact the GP and make a note of that in the notes.

Write down WHO you spoke to in the patient notes, the date and time.

Document that e-mail in the notes, document that phone conversation in the notes.

Had a solicitor in the chair 2 years ago, "the number of cases that have been won/lost because that phone call/e-mail was/was not recorded in the notes is untrue."

There was an article about this in the Diabetic Foot Journal!

In any case of litigation, it is the person with the more convincing/accurate account of events that wins!