Vascular (3) (History taking and examination)

Question 1

vascular history taking: PC

Answer 1

• Pain in the calf on walking.
• Pain in the foot at night.
• Noticed a toe has become discoloured.
• Ulceration.

Question 2

vascular history taking: HPC

Answer 2

• SOCRATES
  
  • Where do you get it
  • When does it come on
  • Describe it
  • Does it radiate anywhere
  • Do you get any other symptoms with it
  • How long does it last
  • And exacerbating or relieving factors
  • How severe is it
• In claudication the pain is typically
  
  • Localised to the calf and sometimes the buttock
  • Aching cramping/tight
  • Relieved with rest
  • Occurring after consistent distance
  • Relived after consistent rest time
  • Inclined to pass without the patient needing to sit down

Question 3

important questions to ask for PAD

Answer 3

• important to ask how far patient can walk (try and quantify in M)
• pain at night → critical limb threatening ischaemia
  
  • less gravity
  • blood pressure decreases at night → reduced blood flow
  • may sleep in a chair

Question 4

vascular history taking: PMH

Answer 4

• Diabetes
• High blood pressure
• High cholesterol
• Any heart problems
• Stroke?
• Any problems with arteries
• Have you ever had an operation
• Do you see a doctor for any other conditions

Question 5

vascular history taking: Fx

Answer 5

• Vascular conditions

Question 6

vascular history taking: Dx

Answer 6

• Are you currently taking any medication?

Question 7

vascular history taking: allergies

Answer 7

• Do you have any allergies

Question 8

vascular history taking: social history

Answer 8

• General context
  
  • Who do you live with
  • ADR- very important
  • Carer support?
• Do you smoke?
• Do you drink?
• Any travel or periods of immobility recently

Question 9

PAD exam: intro

Answer 9

• Wash your hands and don PPE if appropriate.
• Introduce yourself to the patient including your name and role.
• Confirm the patient’s name and date of birth.
• Briefly explain what the examination will involve using patient-friendly language.
• Gain consent to proceed with the examination.
• Adequately expose the patient’s limbs and abdomen for the examination (offer a blanket to allow exposure only when required).
• Position the patient on the bed, with the head of the bed at 45°.
• Ask the patient if they have any pain before proceeding with the clinical examination.

Question 10

PAD exam: general inspection (from end of the bed)

Answer 10

Clinical signs

• Missing limbs/digits
• Scars

Objects and equipment

• Medical equipment
• Mobility aids
• Vital signs
• Prescriptions

Question 11

PAD exam: upper limb inspection

Answer 11

Inspect and compare the upper limb

• Peripheral cyanosis: bluish discolouration of the skin associated with low SpO₂ in the affected tissues (e.g. may be present in the peripheries in PVD due to poor perfusion).
• Peripheral pallor: a pale colour of the skin that can suggest poor perfusion (e.g. PVD).
• Tar staining: caused by smoking, a significant risk factor for cardiovascular disease (e.g. PVD, coronary artery disease, hypertension).
• Xanthomata: raised yellow cholesterol-rich deposits that are often noted on the palm, tendons of the wrist and elbow. Xanthomata are associated with hyperlipidaemia (typically familial hypercholesterolaemia), another important risk factor for cardiovascular disease.
• Gangrene: tissue necrosis secondary to inadequate perfusion. Typical appearances include a change in skin colour (e.g. red, black) and breakdown of the associated tissue.

Question 12

PAD exam: upper limb palpation

Answer 12

• Temperature
  
  • Place the dorsal aspect of hand onto the patients upper limbs to assess temperature
  • Should be symmetrically warm
• Capillary refill time
  
  • Apply for 5 seconds
  • Should return to normal colour in less than 2s
• Pulses
  
  • Radial pulse
    
    • Rate and rhythm
  • Radial-radial delay
    
    • Describes a loss of synchronicity between the radial pulses one ach arm
    • Causes
      
      • Subclavian artery stenosis
      • Aortic dissection
  • Brachial pulse
    
    • Volume and character
    • Palpate medial to the bicep brachii tendon and lateral to the medial epicondyle of the humerus
    • Deep palpation is require
  • Carotid pulse
    
    • Located between the larynx and the anterior border of the SM
    • Auscultate
      
      • Bruit- carotid stenosis or radiating cardiac murmur (aortic stenosis)
        
        • Get pt to take a deep breath and hold whilst you listen
    • Palpate- only if not bruit identified
      
      • Assess for character and volume
• Blood pressure
  
  • In both arms
  • Wide pulse pressure (more than 100 mmHg of difference between systolic and diastolic blood pressure) can be associated with aortic regurgitation and aortic dissection.
  • A more than 20 mmHg difference in BP between arms is abnormal and is associated with aortic dissection.

Question 13

PAD exam: abdomen inspection

Answer 13

Inspection

• Inspect abdomen looking for obvious pulsation – AA located in midline fo epigastrium

Palpation

• AA

Auscultation to identify bruit

• Aorta
  
  • Aortic bruits: auscultate 1-2cm superior to the umbilicus, a bruit here may be associated with AAA
• Renal arteries
  
  • Ausculate 1-2cm superior to the umbilicus slightly lateral to the midline on each side
  • Renal artery stenosis

Question 14

PAD exam: lower limb inspection (compare)

Answer 14

• Peripheral cyanosis: bluish discolouration of the skin associated with low SpO₂ in the affected tissues (e.g. may be present in the peripheries in PVD due to poor perfusion).
• Peripheral pallor: a pale colour of the skin that can suggest poor perfusion.
• Ischaemic rubour: a dusky-red discolouration of the leg that typically develops when the limb is dependent. Ischaemic rubour occurs due to the loss of capillary tone associated with PVD.
• Venous ulcers: typically large and shallow ulcers with irregular borders that are only mildly painful. These ulcers most commonly develop over the medial aspect of the ankle.
• Arterial ulcers: typically small, well-defined, deep ulcers that are very painful. These ulcers most commonly develop in the most peripheral regions of a limb (e.g. the ends of digits).
• Gangrene: tissue necrosis secondary to inadequate perfusion. Typical appearances include a change in skin colour (e.g. red, black) and breakdown of the associated tissue.
• Missing limbs, toes, fingers: due to amputation secondary to critical ischaemia.
• Scars: may indicate previous surgical procedures (e.g. bypass surgery) or healed ulcers.
• Hair loss: associated with PVD due to chronic impairment of tissue perfusion.
• Muscle wasting: associated with chronic peripheral vascular disease.
• Xanthomata: raised yellow cholesterol-rich deposits that may be present over the knee or ankle. Xanthomata are associated with hyperlipidaemia (typically familial hypercholesterolaemia), another important risk factor for cardiovascular disease.
• Paralysis: critical limb ischaemia can cause weakness and paralysis of a limb. To perform a quick gross motor assessment, ask the patient to wiggle their toes.

Question 15

PAD exam: lower limb palpation

Answer 15

• Temperature
• CRT (distal phalanx)
• Pulses
  
  • femoral
  • popliteal
  • posterior tibial pulse
  • dorsalis pedis pulse
• sensation

Question 16

Femoral pulse

Answer 16

• Where: mid-inguinal point (halfway between the anterior superior iliac spine and pubic symphysis )
• Assess for
  
  • Radio femoral delay
    
    • Palpate the femoral pulse and radial pulse simultaneously.
    • In healthy individuals, the pulses should occur at the same time.
    • If the pulses are out of sync, this indicates radio-femoral delay
    • Auscultate for bruit à femoral or iliac stenosis

Question 17

Popliteal

Answer 17

• The popliteal pulse can be palpated in the inferior region of the popliteal fossa.
• With the patient prone, ask them to relax their legs and place your thumbs on the tibial tuberosity.
• Passively flex the patient’s knee to 30º as you curl your fingers into the popliteal fossa. This should allow you to feel the pulse, as you compress the popliteal artery against the tibia.
• This pulse is often difficult to palpate, so don’t pretend you can feel it if you can’t. The popliteal artery is one of the deepest structures within the fossa, so the examiner will understand if you are unable to locate the artery.

Question 18

posterior tibial

Answer 18

• The posterior tibial pulse can be located posterior to the medial malleolus of the tibia.
• Palpate the pulse to confirm its presence and then compare pulse strength between the feet.

Question 19

Dorsalis pedis pulse

Answer 19

• The dorsalis pedis pulse can be located over the dorsum of the foot, lateral to the extensor hallucis longus tendon, over the second and third cuneiform bones.
• Palpate the pulse to confirm its presence and then compare pulse strength between the feet.

Question 20

sensation

Answer 20

Sensation Slowly progressive peripheral neuropathy is common in patients with significant peripheral vascular disease. This results in a glove and stocking distribution of sensory loss. Acute critical limb ischaemia causes rapid onset parathesia in the affected limb.

Question 21

gross peripheral sensation assessment

Answer 21

Sensation Slowly progressive peripheral neuropathy is common in patients with significant peripheral vascular disease. This results in a glove and stocking distribution of sensory loss. Acute critical limb ischaemia causes rapid onset parathesia in the affected limb.

Question 22

Buergers test

Answer 22

To perform Buerger’s test:

1. With the patient positioned supine, stand at the bottom of the bed and raise both of the patient’s feet to 45º for 1-2 minutes.
2. Observe the colour of the limbs:

• The development of pallor indicates that peripheral arterial pressure is unable to overcome the effects of gravity, resulting in loss of limb perfusion. If a limb develops pallor, note at what angle this occurs (e.g. 25º), this is known as Buerger’s angle.
• In a healthy individual, the entire leg should remain pink, even at an angle of 90º.
• A Buerger’s angle of less than 20º indicates severe limb ischaemia.

1. Sit the patient up and ask them to hang their legs down over the side of the bed:
   
   • Gravity should now aid reperfusion of the leg, resulting in the return of colour to the patient’s limb.
   • The leg will initially turn a bluish colour due to the passage of deoxygenated blood through the ischaemic tissue. Then the leg will become red due to reactive hyperaemia secondary to post-hypoxic arteriolar dilatation (driven by anaerobic metabolic waste products).

Question 23

to complete PAD exam

Answer 23

• Explain to the patient that the examination is now finished.
• Thank the patient for their time.
• Dispose of PPE appropriately and wash your hands.
• Summarise your findings.

Question 24

further assessments for PAD exam

Answer 24

Suggest further assessments and investigations to the examiner:

• Blood pressure measurement: to identify significant discrepancies between the two arms suggestive of aortic dissection.
• Cardiovascular examination: to complete assessment of the vascular system.
• Ankle-brachial pressure index (ABPI) measurement: to further assess lower limb perfusion.
• Upper and lower limb neurological examination: if gross neurological deficits were noted during the peripheral vascular examination.

Question 25

venous examination - also known as varicose vein exam: introduction

Answer 25

• Wash your hands and don PPE if appropriate.
• Introduce yourself to the patient including your name and role.
• Confirm the patient’s name and date of birth.
• Briefly explain what the examination will involve using patient-friendly language: “Today I need to examine the veins in your legs. This will involve me first looking at the veins, then feeling the veins and performing some special tests. You’ll need to take your trousers off for the examination, but you can keep your underwear on.”
• Explain the need for a chaperone: “One of the ward staff members will be present throughout the examination, acting as a chaperone, would that be ok?”
• Gain consent to proceed with the examination.
• Adequately expose the patient’s lower limbs.
• Position the patient standing.
• Ask the patient if they have any pain before proceeding with the clinical examination.

Question 26

venous exam: general inspection at the end of the bed

Answer 26

Clinical signs

• Scars: may indicate previous surgical procedures or healed ulcers.
• Ulcers: indicative of venous and/or arterial disease.

Objects and equipment

• Medical equipment: note any compression stockings and wound dressings.
• Mobility aids: items such as wheelchairs and walking aids give an indication of the patient’s current mobility status.
• Vital signs: charts on which vital signs are recorded will give an indication of the patient’s current clinical status and how their physiological parameters have changed over time.
• Prescriptions: prescribing charts or personal prescriptions can provide useful information about the patient’s recent medications.

Question 27

venous exam: leg inspection

Answer 27

With patient standing look for signs of venous disease from the front, side and back of the legs

• Surgical scars
  
  • It is important to note that modern venous treatments are now minimally invasive and therefore they’ll be no scars (NICE now recommends minimally invasive surgery for varicose veins as first-line treatment). Traditional treatment in the past did result in a low groin scaron the affected side.
• Venous (varicose) eczema
• lipodermatosclerosis
• venous ulcers
• saphena varix

Question 28

Venous (varicose) eczema

Answer 28

• Results due to venous hypertension causing fluid to collect in the tissues
• Stasis of this fluid in the soft tissues results in activation of the innate immune response and subsequent inflammation
• Presentation
  
  • Itchy red (intensely), blistered and crusted plaques
  • Atrophie blanche: star-shaped ivory-white depressed atrophic plaques with red dots within the scar (dilated capillaries) and surrounding hyperpigmentation (due to haemosiderin deposition)
• Orange-brown patches od pigmentation caused by haemosiderin deposition
• Lipodermatosclerosis

Question 29

lipodermatosclerosis

Answer 29

• A form of panniculitis (inflammation of the subcutaneous fat) caused by ongoing activation of the innate immune response in soft tissues (secondary to venous hypertension).
• It is an advanced manifestation of chronic venous insufficiency (CVI). Varicose veins are a common cause of CVI with other causes including deep venous incompetence and calf muscle pump failure.
• Presentation
• Skin hardening (often referred to as induration)
• Hyperpigmentation
• Erythema
• Swelling
• Inverted champagne bottle appearance

Question 30

Venous ulcers

Answer 30

• Caused by improper functioning of venous valves and develop along the medial aspect of the distal leg- gaiter area
• Definition: full-thickness defect of the skin that fails to heal spontaneously and is sustained by chronic venous disease
• Presentation
  
  • Large, irregular border with sloping edges
  • Shallow depth
  • Often located over the medial aspect of the ankle (referred to as the gaiter region).
  • Associated with mild pain

Question 31

Saphena varix

Answer 31

• Saphena varix
  
  • A saphena varix is a dilation of the saphenous vein at its junction with the femoral vein in the groin. It typically presents as a lump around 2-4cm inferior-lateral to the pubic tubercle. It often has a bluish tinge, is soft to palpate and will vanish when the patient lies down which can help differentiate it from an inguinal hernia.

Question 32

Varicose veins

Answer 32

Appear as tortuous dilated superficial veins. The location of the varicose vein can help inform you as to which part of the venous system is likely to be affected.

Great saphenous vein

Small saphenous vein

Question 33

Great saphenous vein

Answer 33

• The great saphenous vein originates at the merging of the dorsal vein of the big toe with the dorsal venous arch of the foot. After passing in front of the medial malleolus (where it often can be visualized and palpated), it runs up the medial side of the leg (classically known as the trouser seam).
• At the knee, it runs over the posterior border of the medial epicondyle of the femur bone. In the proximal anterior thigh 3-4 centimetres inferolateral to the pubic tubercle, the great saphenous vein dives down deep through the cribriform fascia of the saphenous opening to join the femoral vein. ¹

Question 34

Small saphenous vein

Answer 34

• The small saphenous vein originates at the merging of the dorsal vein of the fifth digit with the dorsal venous arch of the foot. From its origin, it courses around the lateral aspect of the foot (inferior and posterior to the lateral malleolus) and runs along the posterior aspect of the leg, where it passes between the heads of the gastrocnemius muscle.
• The small saphenous vein drains into the popliteal vein, at or above the level of the knee joint.² The saphenopopliteal junction (SPJ) is anatomically more variable in position compared to the saphenofemoral junction (SFJ).

Summary

In summary, the great saphenous vein runs all the way up the medial side of the leg and the small saphenous vein drains the lateral side of the lower leg. Varicose veins on the buttocksand around the genitals are suggestive of pathology affecting the venous system within the pelvis.

Question 35

Assess varicosities

Answer 35

• Temperature
• Palpation
  
  • Palpate the entire length of each varicosity and ask the patient to let you know if they experience any pain.
  • Overlying erythema in the distribution of the vessel and tenderness on palpation is indicative of phlebitis.
    
    • Inflammation of a vein
  • A tender and hard (“cord-like”) varicosity is indicative of thrombophlebitis (thrombosis with associated inflammation).

Question 36

venous exam:Further assessment of the lower limb

Answer 36

• Pitting oedema
• Lower limb pulses
  
  • Femoral pulse
  • Popliteal
  • Posterior tibial pulse
  • Dorsalis pedis pulse
• Percussion
  
  • The tap test provides a crude assessment of lower limb venous valve competency. It is rarely performed in modern clinical practice, but it is worth understanding what the test involves.
• Auscultation
  
  • Again, auscultation is rarely performed in modern clinical practice and has largely been replaced by modern venous duplex scanning.
  • Auscultation involves placing the bell of the stethoscope over the identified varicosity and then listening for a bruit. A bruit indicates turbulent blood flow which may suggest an underlying arteriovenous malformation.

Question 37

venous exam: To complete the examination…

Answer 37

• Explain to the patient that the examination is now finished.
• Thank the patient for their time.
• Dispose of PPE appropriately and wash your hands.
• Summarise your findings.z

Question 38

venous exam: Further assessments and investigations

Answer 38

Suggest further assessments and investigations to the examiner:

• Doppler ultrasound: to enable further bedside assessment of incompetent venous valves and the identification of thrombosis.
• Venous duplex scanning: for a comprehensive assessment of lower limb venous drainage.
• Ankle-brachial pressure index (ABPI) measurement: to assess arterial perfusion.
• Peripheral arterial examination: to assess for evidence of arterial disease.
• Abdominal examination: occasionally increased pressure in the abdomen or pelvis (e.g. a large tumour) can occlude venous return from the legs leading to venous hypertension and varicose veins.

Question 39

Diabetic foot assessment

Gather equipment

Answer 39

The following pieces of equipment may be required:

• Monofilament
• Tuning fork (128 Hz)
• Tendon hammer

Question 40

diabetic foot assessment: intro

Answer 40

• Wash your hands and don PPE if appropriate.
• Introduce yourself to the patient including your name and role.
• Confirm the patient’s name and date of birth.
• Briefly explain what the examination will involve using patient-friendly language.
• Gain consent to proceed with the examination.
• Adequately expose the patient’s lower limbs.
• Position the patient on the bed, with the head of the bed at 45°.
• Ask the patient if they have any pain before proceeding with the clinical examination.

Question 41

diabetic foot assessment:: inspection

Answer 41

Inspect the lower limbs for relevant pathology, making sure to look at the posterior aspect of each leg and between each of the toes for hidden ulcers:

• Peripheral cyanosis: bluish discolouration of the skin associated with low SpO₂ in the affected tissues (e.g. may be present in PVD due to poor perfusion).
• Peripheral pallor: a pale colour of the skin that can indicate poor perfusion.
• Venous ulcers: typically large and shallow ulcers with irregular borders that are only mildly painful. These ulcers most commonly develop over the medial aspect of the ankle.Arterial ulcers: typically small, well-defined, deep ulcers that are very painful. These ulcers most commonly develop in the most peripheral regions of a limb (e.g. the ends of digits).
• Gangrene: tissue necrosis secondary to inadequate perfusion. Typical appearances include a change in skin colour (e.g. red, black) and breakdown of the associated tissue.
• Missing limbs, toes, fingers: due to amputation secondary to critical ischaemia.
• Scars: may indicate previous surgical procedures (e.g. bypass surgery) or healed ulcers.
• Hair loss: occurs due to chronic impairment of tissue perfusion in PVD.
• Foot calluses: often caused by an abnormal gait and/or poorly fitting footwear.
• Venous guttering: veins that have very little blood within them due to poor blood supply to the limb, hence the “guttered” appearance

Question 42

diabetic foot exam: palpation

Answer 42

• Temperature
  
  • Place the dorsal aspect of your hand onto the patient’s lower limbs to assess and compare temperature
• CRT
  
  • Hold for 5 should eb back to normal in <2s
• Pulses
  
  • Posterior tibial pulse
  • dorsalis pedis pulse

Question 43

diabetic foot assessment: monofilament

Answer 43

1. Provide an example of the monofilament sensation on the patient’s arm or sternum.

2. With the patient’s eyes closed, apply the monofilament to each of the following locations in turn:

• The pulp of the hallux.
• The pulp of the third digit.
• Metatarsophalangeal joints 1, 3 and 5.

3. When applying the monofilament to each area:

• Ask the patient to report when they feel the monofilament touch their foot.
• Press the monofilament against the skin until it bends slightly (this will ensure that only 10g of pressure is applied).
• Hold the monofilament against the skin for 1-2 seconds.
• Avoid calluses and scars as they have a reduced level of sensation that is not representative of the surrounding tissue.

Question 44

diabetic foot exam: vibration sensation

Answer 44

1. Ask the patient to close their eyes and to let you know both when they can detect vibration and when it stops.
2. Tap a 128 Hz tuning fork and place onto the patient’s sternum to check they are able to feel it vibrating. Then grasp the ends of the tuning fork to cease vibration and see if the patient is able to accurately identify that it has stopped.
3. Tap the tuning fork again and place onto the interphalangeal joint of the patient’s big toe. If the patient is able to accurately identify when the vibration begins and when it stops at this point in both lower limbs, the assessment is complete.
4. If vibration sensation is impaired at the interphalangeal joint of the patient’s big toe, continue to sequentially assess more proximal joints (e.g. metatarsophalangeal joint of the big toe → ankle joint → knee joint) until the patient is able to accurately identify vibration.

Question 45

diabetic foot assessment: proprioception

Answer 45

Proprioception, also known as joint position sense, involves the dorsal columns.

1. Begin assessment of proprioception at the interphalangeal joint of the big toe by holding the distal phalanx of the big toe by its sides (avoid holding the nail bed as this can allow the patient to determine direction based on pressure).
2. Demonstrate movement of the big toe “upwards” and “downwards” to the patient whilst they watch.
3. Ask the patient to close their eyes and state if you are moving their big toe up or down.
4. Move the big toe up or down 3-4 times in a random sequence to see if the patient is able to accurately identify joint position with their eyes closed.
5. If the patient is unable to correctly identify the direction of movement, continue to sequentially assess more proximal joints (e.g. metatarsophalangeal joint of the big toe → ankle joint → knee joint).

Question 46

diabetic foot assessment: ankle jerk reflex

Answer 46

Assess the ankle-jerk reflex (S1) in each of the patient’s lower limbs.

There are several methods for eliciting the ankle-jerk reflex, with two of the most common explained below.

The ankle jerk reflex may be absent in advanced peripheral neuropathy.

Method 1

1. With the patient on the examination couch support their leg so that their hip is slightly abducted, the knee is flexed and the ankle is dorsiflexed.
2. Tap the Achille’s tendon with the tendon hammer and observe for a contraction in the gastrocnemius muscle with associated plantarflexion of the foot.

Method 2

1. Ask the patient to kneel on a chair and hold the back of it to steady themselves.
2. Tap the Achille’s tendon with the tendon hammer and observe for a contraction in the gastrocnemius muscle with associated plantarflexion of the foot.

Question 47

diabetic foot assessment: gait

Answer 47

Peripheral neuropathy associated with diabetic foot disease can result in the development of an abnormal gait. Patients with peripheral neuropathy may demonstrate a conservative gait strategy in which their walking speed is reduced and their foot stance is broadened. The development of foot drop is also more common in diabetic patients, which can result in a high-stepping gait.

Assess the patient’s gait

Patients with diabetic foot disease are often at an increased risk of falls so make sure to remain close to the patient during the assessment so that you are able to intervene if required.

Ask the patient to walk to the end of the examination room and then turn and walk back whilst you observe their gait paying attention to:

• Speed: gait speed may be reduced significantly in patients with advanced peripheral neuropathy.
• Stance: a broad-based gait may be associated with advanced peripheral neuropathy to increase stability.
• Steps: high-stepping may indicate the presence of foot drop.
• Turning: patients with peripheral neuropathy can find turning difficult and they may look down at their feet whilst turning due to impairment of sensation and proprioception.

Question 48

diabetic foot assessment: footwear

Answer 48

The use of appropriate footwear is particularly important for diabetic patients due to the presence of impaired sensation and poor peripheral perfusion. Inappropriately fitting footwear or foreign objects within a shoe can result in significant tissue injury and the formation of a diabetic foot ulcer.

Inspect the patient’s footwear:

• Note the pattern of wear on the soles (asymmetrical wearing may indicate an abnormal gait).
• Check that the shoes are the correct size for the patient.
• Ensure there are no materials within the shoe that could cause foot injury.

Question 49

diabetic foot exam: to complete

Answer 49

• Explain to the patient that the examination is now finished.
• Thank the patient for their time.
• Dispose of PPE appropriately and wash your hands.
• Summarise your findings.

Question 50

diabetic foot assessment: further assessments

Answer 50

• Bedside capillary blood glucose: if there is concern that the patient is currently hyperglycaemic or hypoglycaemic.
• Serum HbA1c: to aid assessment of blood glucose control over the previous three months.
• Lower limb neurological examination: if diabetic foot examination reveals neurological deficits.
• Peripheral arterial examination: if diabetic foot examination identifies clinical signs suggestive of arterial disease.
• Venous examination of the lower limbs: if diabetic foot examination identified clinical signs suggestive of venous disease.
• Foot care advice: including regular podiatry input and appropriate footwear.
• Calculation of diabetic foot risk using assessment tool: based on the clinical findings of the diabetic foot examination.