Diabetic Foot Examination Flashcards
What should be done in the introduction of a diabetic foot exam?
- Wash hands
- Introduction, identification and consent
- Ask if any pain in feet or ankles
What should be noted on inspection on diabetic foot?
- Gait
- Shoes
- Skin
- Feet specifically
What are the four things to note when assessing the gait of a diabetic foot patient?
- Speed
- Stance
- Steps
- Turning
In what condition is gait speed reduced in a diabetic foot exam?
Advanced peripheral neuropathy
Which type of stance may indicate an advanced peripheral neuropathy and why?
- A broad-based gait
- Done to increase stability
What kind of steps indicates the presence of foot drop?
High-stepping
What may present with turning in patients with peripheral neuropathy and why?
- May find it difficult
- May look down at their feet while turning
- This is due to impairment of sensation and proprioception
What are the three things to note about footwear in a diabetic foot exam?
- Pattern of wear of the soles
- Check the shoes are the correct size
- Ensure no materials in the shoe which may cause injury
What may asymmetrical wear of the shoes mean in a diabetic foot patient?
An abnormal gait
What changes to the skin should be noted in a diabetic foot patient?
- Trophic changes
- Pallor/cyanosis
- Rubor at pressure points
- Ulceration
- Dermopathy
- Infection
- Changes to toenails
- Missing digits/limbs
- Scars
- Calluses
- Venous guttering
- Charcot arthropathy
What are trophic changes of the foot?
- Pallor
- Decreased sweating (autonomic dysfunction)
- Dry cracked skin
What does hair loss of the feet/legs indicate in a diabetic patient?
Chronic impairment of tissue perfusion in PVD
What is peripheral pallor?
A pale colour of the skin that can indicate poor perfusion
What is peripheral cyanosis?
Bluish discolouration of the skin associated with low SpO2 in the affected tissues
What can occur at the pressure points in a diabetic foot patient?
Rubor
What are the two types of ulceration which can occur in a diabetic foot patient?
Venous & arterial
How do venous ulcers present?
- Large and shallow
- Irregular borders
- Mildly painful
Where do venous ulcers usually present?
The medial aspect of the ankle
How do arterial ulcers present?
- Small and deep
- Well defined border
- Very painful
Where do arterial ulcers usually present?
The most peripheral regions of a limb
Where does diabetic dermopathy usually present and what is it?
Brown macule - over the shin
What are the two types of infection which can present with diabetic foot?
Cellulitis & gangrene
How does cellulitis present?
Erythema & swelling
What is the brief pathophysiology of gangrene?
Tissue necrosis secondary to inadequate perfusion
What is the typical appearance of gangrene?
Change in skin colour and breakdown of associated tissue
What may occur between the fingers/toes in a diabetic foot exam?
- Cracks
- Infections
- Ulcers
- Maceration
What are the 4 things which would occur on the toenails in a diabetic foot exam?
- Dystrophy
- Ingrowing toe nails
- Paronychia (infection of the nails)
- Onychomycosis (fungal infection of the nail)
What may missing fingers/limbs/toes mean on a diabetic foot exam?
Amputation secondary to critical ischaemia
What may scars indicate on a diabetic foot exam?
Previous surgical procedures e.g. bypass surgery or healed ulcers
What may foot calluses indicate on a diabetic foot exam?
An abnormal gait and/or poorly fitting footwear
What is venous guttering and when is it present?
- When veins have a small blood supply, due to poor supply, so gives a ‘guttered appearance’
- May be present with diabetic foot
What is Charcot arthropathy?
The progressive degeneration of a weight-bearing joint due to peripheral neuropathy
What are the 4 typical features of a Charcot’s joint?
- Effusion
- Distortion
- Overlying erythema
- Loss of joint function
What 3 deformities would you inspect for in diabetic foot?
- Intrinsic muscle wasting
- Per planus
- Pes cavus
What are the features of intrinsic muscle wasting of the foot in diabetic foot?
Clawed, hammer toes
What is per planus?
Flat foot
What is pes caves?
High arch in the foot
What is included in the general palpation of diabetic foot?
- Bones and joint of the ankle & foot for swelling + tenderness
- Watch the patient’s face for discomfort
What is included in the vascular palpation of diabetic foot?
- Temperature
- Pulses
- Capillary refill
How do you assess the temperature of the feet in a diabetic foot exam?
- Using the back of the hands, compare the shins to feet bilaterally
- Should decrease slightly as you move distally
What is a normal temperature pattern of the feet in a diabetic foot examination?
The lower limbs should be symmetrically warm, suggesting adequate perfusion
What does a cool and pale limb indicate?
Poor arterial perfusion
What are the 4 pulses which may be tested in a diabetic foot examination?
- Femoral
- Popliteal
- Posterior tibial
- Dorsalis pedis
How is the posterior tibial pulse tested in a diabetic foot examination?
- Can be located posterior to the medial malleolus of the tibia
- Palpate the pulse to confirm its presence and then compare pulse strength between the feet
How is the dorsals pedis pulse tested in a diabetic foot examination?
- Can be located over the dorsum of the foot, lateral to the extensor hallucis longus tendon, over the second and third cuneiform bones
- Palpate the pulse to confirm its presence and then compare pulse strength between the feet
What are the two main components of the neuro examination in diabetic foot?
- Reflexes
- Sensation
What reflex is tested in a diabetic foot patient and how is it done?
- Ankle jerk reflex
- Get the leg so the knee is slightly bent and the foot is facing outwards
- Tap the Achille’s tendon and see if there is plantar flexion of the foot
What is the myotome of the ankle-jerk reflex and what may its absence show?
- S1
- Advanced peripheral neuropathy
How is sensation with a monofilament tested in a diabetic foot exam?
- Allow them to feel the sensation on their arm
- Place on the inside of the big toe, the inside of the third digit & Metatarsophalangeal joint 1, 3 & 5
What should you avoid when using monofilaments in a diabetic foot exam?
Calluses and scars as they have a reduced level of sensation
How is proprioception of the feet assessed in the diabetic foot exam?
- The upwards and downwards (movement of the joint and get the patient to tell you which way it went) test of the interphalangeal joint of the big toe
- If they can’t assess it = sequentially assess the more proximal joints
How do you assess the neurological exam of the diabetic foot exam using vibration?
- Ask the patient to close their eyes
- Test the tuning fork on their sternum first so they known when it begins/ends
- Place on the interphalangeal joint of the patient’s big toe.
- Continue up sequentially if they can’t identify on the toe
What are the different ways to test sensation on a diabetic foot exam?
- Monofilament
- Light touch (with cotton wool)
- Pressure
- Pin prick
- Temperature
- Proprioception
- Vibration
Name 7 further examinations/imaging/investigations after a diabetic foot examination
- Bedside capillary blood glucose
- Serum HbA1c
- Lower limb neurological examination
- Peripheral arterial examination
- Venous examination of the lower limbs
- Foot care advice
- Calculation of diabetic foot risk using assessment tool
