Diabetic lower limb

Question 1

Give 6 systems which may be affected in diabetes

Answer 1

Vascular
* GI
* GUS
* NS
* Eyes
* General e.g. infections

Question 2

Give 3 microvascular complications of diabetes

Answer 2

Retinopathy
Nephropathy
Neuropathy

Question 3

Give 3 macrovascular Complications of Diabetes

Answer 3

Coronary artery disease
Peripheral artery disease
Stroke

Question 4

What is the difference between microvascular and microvascular complications?

Answer 4

Microvascular
– Damage correlates with poor glycaemic control

Macrovascular
– Less correlation with level of glycaemic control

Question 5

Give 4 Biochemical Complications of diabetes

Answer 5

Ketone
Plasma glucose
HbA1c
Osmolality

Question 6

Give 5 Complications of Autonomic Neuropathy

Answer 6

Dizziness + fainting, BP
Incompetence
Renal failure
Gastroparesis
Sweat, cannot regulate body temp (infected and cracked feet)

Question 7

What is the commonest Gram negative pathogen in community acquired urinary tract infection?

Answer 7

E.coli

Question 8

What would be an appropriate antibiotic to prescribe for that pathogen?

Answer 8

Co-trimoxazole

Question 9

List 7 Symptoms linked to diabetes

Answer 9

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

Question 10

What should be asked in the history ?

Answer 10

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

Question 11

What factors are important in the family and social history?

Answer 11

FH - Immune issues

SH - Drinking, smoking, weight

Question 12

Suggest 4 areas that should be covered in the diet history

Answer 12

How much ?
How often?
What?
What do you think of your diet ?
Specific

Question 13

Summarise (classify) the oral medications available to lower glucose in T2DM ?

Answer 13

1 Biguanide
2 Sulphonylureas
3 Thiazolidinedones
4 DPP-4 Inhibitors (Gliptins)
5 SGLT2 Inhibitors
6 Meglitinides
(7 Alpha- glucosidase inhibitor)

Question 14

What areas have to be covered in the diabetes examination?

Answer 14

• General inspection
• Pulse and BP
• Lower limbs neurovascular
• Eyes (ophthalmoscopy)
• Urine analysis – glucose, infection, protein (nephropathy)
• Mouth (infection)
• (Upper limbs neurovascular)

Question 15

What areas should you concentrate on ?

Answer 15

• Pulses & BP
• Extremities, The “diabetic foot” – the neuro-ischaemic foot
• Eyes
• Infections

Question 16

What is considered a diabetic foot?

Answer 16

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

Question 17

What stages should you examination of legs in patient with diabetes?

Answer 17

• Inspection
• Palpation
  – Vascular
  – Sensory system
• Motor system
  – Reflexes
  – Gait

Question 18

What should be included in inspection?

Answer 18

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

Question 19

What should be included in Palpation?

Answer 19

Palpation
* Assess temperature of limbs
* Check capillary refill time
* Assess pulses both limbs: dorsalis pedis, posterior tibial, popliteal

Question 20

What should be included in Sensory?

Answer 20

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

Question 21

What should be included in motor?

Answer 21

Motor
* Reflexes
* Gait

Question 22

What should be assessed in the eyes?

Answer 22

Diabetic Retinopathy and Classified;

Classification;
* Background
* Pre-proliferative
* Proliferative retinopathy
* Macular oedema

Question 23

What are the clinical features of background retinopathy?

Answer 23

Clinical Features;
 Microaneurysms
Hard exudates
Retinal oedema
 Haemorrhages

Question 24

What would you want to assess for in your management plan and list 4 relevant blood investigations?

Answer 24

Management Plan;
* Bloods:
1. Glucose
2. Ketones
3. WBC’s
4. RBC’s/HBA1c
* Swabs
* Urine
* Medications

Question 25

Why are monofilaments used?

Answer 25

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.

Question 26

How is the monofilament used?

Answer 26

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.

Question 27

When should the monofilament be replaced ?

Answer 27

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