Diabetic foot examination Flashcards
What are the first steps of an introduction in a exam?
Wash hands
Introduce self
Patient details
WHow would you explain a diabetic foot examination to a patient?
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?
What else would you in a diabetic foot exam introduction?
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.
What do you inspect in a diabetic foot exam?
Gait
Shoes
Skin
Feet
When inspecting the gait what are you looking for?
Is the patient demonstrating a normal heel strike/toe off gait?
Is each step of normal height?
Is the gait smooth + symmetrical?
If someone has a high-steppage gait what would this indicate?
foot drop
secondary to common peroneal nerve palsy/sciatic nerve palsy i.e. after total hip replacement
When inspecting a persons shoes what are you looking for?
uneven wear
foreign objects
When looking at the skin of the feet what are you looking for?
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.
When inspecting the feet what are you looking for?
Deformities (Charcot arthropathy).
Intrinsic muscle wasting (clawed, hammer toes).
Flat foot or high arch.
What do you palpate during a diabetic foot exam?
Bone and joints of foot and ankle
MTP squeeze
Ankle joint
When palpating what should you also do?
Watch the patient’s face throughout
Ask if they have any discomfort.
What else should be palpated?
Foot pulses
Temperature of feet and shins bilaterally
CRT
How should you assess the pulses ?
Start distally with Dorsalis pedis and posterial tibial
If neither can be felt then try popiteal
What might a low foot temperature indicate?
poor peripheral perfusion
What might a high foot temperature indicate?
?cellulitis
?DVT
What might absence of foot pulses indicate?
Peripheral vascular disease
What reflexes are examined in a diabetic foot exam?
Ankle jerk
What different modalities of sensation do we test in a diabetic foot exam?
Light touch
Pressure
Proprioception
Vibration
How is light touch examined?
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
How is pressure sensation examined?
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.
How is proprioception examined?
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
What Hz tuning fork should be used?
128 hz
How is vibration sense examined?
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.
Upon finishing the exam what should you do first?
Thank the patient
Wash hands
To complete my exam…
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
Summarise a normal DM foot exam
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