Diabetic foot examination

Question 1

What are the first steps of an introduction in a exam?

Answer 1

Wash hands
Introduce self
Patient details

Question 2

WHow would you explain a diabetic foot examination to a patient?

Answer 2

I’ve been asked to examine your feet today, it’s going to involve me having a general inspection, feel some areas of your feet and testing your sensation, would that be okay?

Question 3

What else would you in a diabetic foot exam introduction?

Answer 3

For this I’m going to need you to be exposed from the knee down if that’s okay?

Would you like a chaperone?

Ask if patient currently has any pain or discomfort in ankles/feet.

Question 4

What do you inspect in a diabetic foot exam?

Answer 4

Gait
Shoes
Skin
Feet

Question 5

When inspecting the gait what are you looking for?

Answer 5

Is the patient demonstrating a normal heel strike/toe off gait?

Is each step of normal height?

Is the gait smooth + symmetrical?

Question 6

If someone has a high-steppage gait what would this indicate?

Answer 6

foot drop

secondary to common peroneal nerve palsy/sciatic nerve palsy i.e. after total hip replacement

Question 7

When inspecting a persons shoes what are you looking for?

Answer 7

uneven wear
foreign objects

Question 8

When looking at the skin of the feet what are you looking for?

Answer 8

Trophic changes -
- Hairlessness
- Pallor.
- Decreased sweating
(ANS dysfunction).
- Dry cracked skin.

Rubor at pressure points.

Skin ulceration.

Diabetic dermopathy
- (brown macules) over
the shins.

Infection;
- Cellulitis
- Gangrene.

Web-spaces of every individual toe;
- Cracked, infected,
ulcers, maceration
(wrinkles).

Toenails;
- Dystrophic.
- In growing toenails.
- Nail and skin meeting
base of foot.
- Fungal infections.

Question 9

When inspecting the feet what are you looking for?

Answer 9

Deformities (Charcot arthropathy).

Intrinsic muscle wasting (clawed, hammer toes).

Flat foot or high arch.

Question 10

What do you palpate during a diabetic foot exam?

Answer 10

Bone and joints of foot and ankle
MTP squeeze
Ankle joint

Question 11

When palpating what should you also do?

Answer 11

Watch the patient’s face throughout
Ask if they have any discomfort.

Question 12

What else should be palpated?

Answer 12

Foot pulses
Temperature of feet and shins bilaterally
CRT

Question 13

How should you assess the pulses ?

Answer 13

Start distally with Dorsalis pedis and posterial tibial

If neither can be felt then try popiteal

Question 14

What might a low foot temperature indicate?

Answer 14

poor peripheral perfusion

Question 15

What might a high foot temperature indicate?

Answer 15

?cellulitis
?DVT

Question 16

What might absence of foot pulses indicate?

Answer 16

Peripheral vascular disease

Question 17

What reflexes are examined in a diabetic foot exam?

Answer 17

Ankle jerk

Question 18

What different modalities of sensation do we test in a diabetic foot exam?

Answer 18

Light touch
Pressure
Proprioception
Vibration

Question 19

How is light touch examined?

Answer 19

using cotton wool lightly brush it against pt forehead / sternum asking if they can feel it.

If so explain that you are going to do the same on their foot and ask them to close their eyes and say yes when they can feel it.

starting distally and move proximally if absent

Question 20

How is pressure sensation examined?

Answer 20

Apply a 10 g mono filament to the pt sternum or forehead for comparison

Ask them to close their eyes and say yes when they can feel it.

Apply on pulp of hallux + the 1st/3rd/5th metatarsal heads so it bends slightly to ensure only 10g is applied.

Hold for 1–2 seconds.

Question 21

How is proprioception examined?

Answer 21

Hold the distal phalanx of their big toe by its sides.

Demonstrate the movement of the toes upwards + downwards to the patient whilst they watch.

Ask patient to close their eyes + state if you are moving toes up/down.

If patient is unable to correctly identify the direction then move to a more proximal joint in this order:
- Big toe -> Ankle ->
Knee -> Hip

Question 22

What Hz tuning fork should be used?

Answer 22

128 hz

Question 23

How is vibration sense examined?

Answer 23

Strike tuning fork and place on pt sternum for comparison and ask then to close their eyes

Place on distal phalanx joint of big toe + ask if they can feel it buzzing + if they feel it stop.

If vibration sensation is impaired, continue to assess the bony prominence of more proximal joints –
Proximal phalanx -> Ankle -> Knee -> Hip.

Question 24

Upon finishing the exam what should you do first?

Answer 24

Thank the patient

Wash hands

Question 25

To complete my exam…

Answer 25

I’d like to perform fundoscopy, check pin prick sensation to both feet, measure blood pressure, perform an ABPI and take blood to measure the HbA1c

Question 26

Summarise a normal DM foot exam

Answer 26

Today I performed a diabetic foot examination on _____ an ___ year old ____.

On general inspection, _____ appeared comfortable at rest.

No abnormalities were detected on inspection.

Gait was normal

On palpation, there was no tenderness and foot pulses were present

Sensation was intact in both feet

To conclude, this is consistent with a normal diabetic foot examination