Diabetic lower limb Flashcards
Give 6 systems which may be affected in diabetes
Vascular
* GI
* GUS
* NS
* Eyes
* General e.g. infections
Give 3 microvascular complications of diabetes
Retinopathy
Nephropathy
Neuropathy
Give 3 macrovascular Complications of Diabetes
Coronary artery disease
Peripheral artery disease
Stroke
What is the difference between microvascular and microvascular complications?
Microvascular
– Damage correlates with poor glycaemic control
Macrovascular
– Less correlation with level of glycaemic control
Give 4 Biochemical Complications of diabetes
Ketone
Plasma glucose
HbA1c
Osmolality
Give 5 Complications of Autonomic Neuropathy
Dizziness + fainting, BP
Incompetence
Renal failure
Gastroparesis
Sweat, cannot regulate body temp (infected and cracked feet)
What is the commonest Gram negative pathogen in community acquired urinary tract infection?
E.coli
What would be an appropriate antibiotic to prescribe for that pathogen?
Co-trimoxazole
List 7 Symptoms linked to diabetes
VS - cardiac symptoms, intermittent claudication, autonomic postural hypotension
GI - diarrhoea, constipation, fungal inf.
GUS - urinary retention, impotence
NS - lower extremity pain, numbness
Eyes - Visual problems
General - Infections
What should be asked in the history ?
History PC
* recent skin or other infections, urinary, mouth
* lower extremity numbness, tingling
* intermittent claudication
* mononeuropathy
* diabetic control
* weight control
* BP control,CVS risk factors
* eyes-eye screening, blurred vision, laser therapy
What factors are important in the family and social history?
FH - Immune issues
SH - Drinking, smoking, weight
Suggest 4 areas that should be covered in the diet history
How much ?
How often?
What?
What do you think of your diet ?
Specific
Summarise (classify) the oral medications available to lower glucose in T2DM ?
1 Biguanide
2 Sulphonylureas
3 Thiazolidinedones
4 DPP-4 Inhibitors (Gliptins)
5 SGLT2 Inhibitors
6 Meglitinides
(7 Alpha- glucosidase inhibitor)
What areas have to be covered in the diabetes examination?
- General inspection
- Pulse and BP
- Lower limbs neurovascular
- Eyes (ophthalmoscopy)
- Urine analysis – glucose, infection, protein (nephropathy)
- Mouth (infection)
- (Upper limbs neurovascular)
What areas should you concentrate on ?
- Pulses & BP
- Extremities, The “diabetic foot” – the neuro-ischaemic foot
- Eyes
- Infections
What is considered a diabetic foot?
The Diabetic Foot - The “neuro-ischaemic” foot
- Peripheral vascular disease
– Loss of foot pulses – Ischaemic foot
– Foot ulceration - Peripheral neuropathy
– Damage due to loss of sensation
– Foot ulceration
What stages should you examination of legs in patient with diabetes?
- Inspection
- Palpation
– Vascular
– Sensory system - Motor system
– Reflexes
– Gait
What should be included in inspection?
Inspection of legs and feet
* Colour: pallor, cyanosis, redness
* Skin: hair loss, dry, eczema, atrophic shiny skin, pustules, abscesses, infections, including fungal infections nails and between toes
* Ulcers: legs, between toes and pressure points. Necrotic and missing toes.
* Deformity:neuropathic joints (Charcot joints due to loss of proprioception)
* Calluses: pressure from incorrectly fitting shoes
What should be included in Palpation?
Palpation
* Assess temperature of limbs
* Check capillary refill time
* Assess pulses both limbs: dorsalis pedis, posterior tibial, popliteal
What should be included in Sensory?
Sensory
* Fine touch 10-g Monofilament: toes, metatarsal heads, heels and dorsum of foot
* Sharp/Dull Sensation: neurotip
* Vibration Sense at great toe: if vibration sense
intact at great toe no need to check further
* Proprioception: ensure hold sides of great toe, avoiding the nail-bed
What should be included in motor?
Motor
* Reflexes
* Gait
What should be assessed in the eyes?
Diabetic Retinopathy and Classified;
Classification;
* Background
* Pre-proliferative
* Proliferative retinopathy
* Macular oedema
What are the clinical features of background retinopathy?
Clinical Features;
Microaneurysms
Hard exudates
Retinal oedema
Haemorrhages
What would you want to assess for in your management plan and list 4 relevant blood investigations?
Management Plan;
* Bloods:
1. Glucose
2. Ketones
3. WBC’s
4. RBC’s/HBA1c
* Swabs
* Urine
* Medications
Why are monofilaments used?
With as many as 30% of people with diabetes suggested having peripheral neuropathy reliable, reproducible methods should be used for screening.
The 10g monofilament is an objective, simple instrument used in screening the diabetic foot for loss of protective sensation.
How is the monofilament used?
Using the Monofilament;
1). Sensory examination should be done in a quiet and relaxed setting. First apply the monofilament on the patient’s inner wrist so the patient knows what to expect.
2). The patient must not be able to see if and where the examiner applies the filament. The five sites to be tested on both feet are the pulp of the hallux and 3rd digit, and MPJs 1, 3 and 5 (see SCI-DC foot screen).
3). Apply the monofilament perpendicular to the skin surface.
4). Apply sufficient force to cause the filament to bend or buckle.
5). The total duration of the approach, skin contact, and removal of the filament should be approximately 2 seconds.
6). Apply the filament along the perimeter of and not on and ulcer site, callus, scar or necrotic tissue. Do not allow the filament to slide across the skin or make repetitive contact at the test site.
7). Press the filament to the skin and ask the patient IF they feel the pressure applied (yes/no) and next WHERE they feel the pressure applied (left/right foot).
8). Loss of Protective Sensation = No Feeling in >/= 8 sites
9). Encourage the patients during testing.
When should the monofilament be replaced ?
The monofilament should be replaced regularly;
Where the device is in use daily for foot screening it should be replaced when it: Looks bent or After 6 months use
When the device is used less frequently it should be replaced when it: Looks bent or After 12 months use
