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Endocrine 1 > Phys Di - Diabetic Foot > Flashcards

Phys Di - Diabetic Foot Flashcards

1
Q

Define neuropathy

A

presence of symptoms and /or signs of peripheral nerve dysfunction in people with diabetes after the exclusion of other causes

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2
Q

Which diabetic neuropathy is MC?

A 
chronic DSPN (distal symmetrical polyneuropathy)
-accounts for 75% of diabetic neuropathies
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3
Q

What is the pathogenesis of neuropathy?

A

oxidative and inflammatory stress, in the context of metabolic dysfunction, damage nerve cells

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4
Q

Incidence and prevalence of DSPN

A
  • occurs in at least 20% of people with T1DM after 20 years of disease duration
  • at least 10-15% of newly diagnosed patients with T2DM have DSPN
  • after 10 years of T2DM disease duration, 50% have DSPN
  • DSPN – small-fiber neuropathy subtype may be present in 10-30% of people with prediabetes or metabolic syndrome.
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5
Q

DSPN is associated with…

A

degree of glycemic control, height, smoking, blood pressure, weight, and lipid measure

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6
Q

Why is DSPN important to comorbidities of the foot?

A

-DSPN is an important cause of foot ulceration
-DSPN is a prerequisite for Charcot foot neuroarthropathy (CN)
-foot ulceration and CN are late complications of DSPN
-these complications drive amputation risk
-they are predictors of mortality
DSPN is a major contributor to falls and fractures

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7
Q

What is Charcot foot?

A
  • loss of arch

- movement of toes

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8
Q

DSPN screening - type 2 vs type 1 DM

A

All patients should be assessed for DSPN starting at diagnosis of T2DM and 5 years after the diagnosis of T1DM and at least annually thereafter

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9
Q

Should you screen DSPN in prediabetes?

A

Yes, consider screening patients with prediabetes who have symptoms of peripheral neuropathy

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10
Q

Symptoms of DSPN

A

-vary according to the class of sensory fibers involved.

MC early symptoms are due to small fiber disease: pain, dysesthesias (unpleasant sensations of burning)

Neuropathic pain:

  • Burning, lancinating, tingling, shooting (electric shock-like)
  • Usually worse at night
  • Exaggerated response to painful stimuli and pan evoked by contact
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11
Q

DSPN of large myelinated nerve fibers

-function, sx, exam

A
  • function: pressure and balance
  • Sx: numbness, tingling, poor balance

Exam:

  • Ankle reflexes: reduced/absent
  • Vibration perception: reduced/absent
  • 10-g monofilament: reduced/absent
  • Proprioception: reduced/absent
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12
Q

Symptoms related to large fiber involvement in DSPN

A

Numbness
-May complain that feet feel like they are wrapped in wool or they are waling on thick socks

Tingling without pain

Loss of protective sensation

  • Loss of the “gift of pain”
  • A risk factor for diabetic foot ulceration
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13
Q

DSPN of small myelinated nerve fibers

-function, sx, exam

A
  • Function: nociception, protective sensation
  • Sx: pain experienced as burning, electric shock, stabbing

Exam:

  • thermal (cold/hot) discrimination: reduced/absent
  • pinprick sensation: reduced/absent
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14
Q

Describe the Pin Prick test

A
  • Disposable pin is applied proximal (skin just below) the big toenail enough to deform the skin
  • Normal exam would be to distinguish sharp/not sharp
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15
Q

Describe the thermal test

A
  • Can the patient distinguish between cold and warm?
  • Simple approach: use tuning fork with beaker of ice/warm water
  • Normal result would be the patient can distinguish hot from cold
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16
Q

How does loss of protective sensation (LOPS) contribute to complications?

A

Loss of protective sensation (LOPS) can render patients unable to recognize damage to their lower extremities, thus creating a cycle of tissue damage and other foot complications.

17
Q

Is the diabetic foot exam performed often enough??

A
  • Strong evidence suggests that consistent provision of foot-care services and preventive care can reduce amputations among patients with diabetes.
  • However, routine foot examination and rapid risk stratification is often difficult to incorporate into busy primary care settings.

**Data suggest that the diabetic foot is adequately evaluated only 12% to 20% of the time

18
Q

Name the 3 components of the ADA Comprehensive Foot Examination and Risk Assessment

A
  1. Taking a patient history,
  2. Performing a physical exam, and
  3. Providing patient education.
19
Q

What patient history should you ask?

A
  • previous leg/foot ulcer or lower limb amputation/surgery
  • prior angioplasty, stent, or leg bypass surgery?
  • foot wound requiring more than 3 weeks to heal?
  • smoking or nicotine use?
  • diabetes (if yes, what are current control measures)?
20
Q

What should you ask about current patient symptoms?

A
  • burning or tingling in legs or feet?
  • leg or foot pain with activity or at rest?
  • changes in skin color or skin lesions?
  • loss of LE sensation?

*has the patient established regular podiatric care?

21
Q

What are the 4 components of diabetic foot exam?

A
  1. Dermatologic,
  2. Neurologic,
  3. Musculoskeletal
  4. Vascular
22
Q

What to look for on derm exam?

A
  • does patient have discolored, ingrown, or elongated toenails?
  • are there signs of fungal infection?
  • does the patient has discolored and/or hypertrophic skin lesions, calluses, or corns?
  • does the patient have open wounds or fissures?
  • does the patient have interdigital maceration?
23
Q

What to look for on neurologic exam?

A

is the patient responsive to the Ipswitch Touch Test?

24
Q

What to look for on musculoskeletal exam?

A
  • does the patient have full range of motion of the joints?
  • does the patient have obvious deformities? If yes, for how long?
  • is the midfoot hot, red, or inflamed?
25
Q

What to look for on vascular exam?

A
  • is the hair growth on the foot dorsum or lower limb decreased?
  • are the dorsalis pedis and posterior tibial pulses palpable?
  • is there a temperature difference between the calves and feet or between the left and right foot?
26
Q

What foot deformities do you look for?

A
  • Prominent metatarsal heads
  • Claw or hammer toes
  • Rocker bottom foot deformity
  • Bunions
  • Prior amputation
27
Q

What 2 arteries should you check for vascular changes?

A

Dorsalis pedis A and posterior tibial A

28
Q

How do you assess biomechanical/mechanical changes?

A
  • *Perform plantar flexion/dorsiflexion of ankles and great toes bilaterally
  • Neuromuscular disturbances, such as a reduction in the strength of dorsiflexion and plantar flexion, may indicate a complicated neurologic compromise.
  • Note foot deformities
29
Q

Patient education: what are the recommendations for daily foot care?

A
  • visually examine both feet, including soles and between toes
  • keep feet dry by regularly changing shoes and socks; dry feet after bath or exercise
  • report any new lesions, discolorations, or swelling to a health care professional
30
Q

Patient education: what are the recommendations for shoes?

A
  • educate patient on risks of walking bare foot, even when indoors
  • recommend appropriate footwear and advise against shoes that re too small, tight, or rub against a particular area of the foot
  • suggest yearly replacement of shoes - more frequently if they exhibit high wear.
31
Q

Patient education: what are the recommendations for overall health risk management?

A
  • recommend smoking cessation (if applicable)

- recommend appropriate glycemic control

Endocrine 1 (18 decks)

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