Diabetic Foot Exam PDF

Diabetic Foot Exam CLINICAL SKILLS II AM&A FLEENOR, MMS, PA-C  Diabetic Foot Statistics  Diabetic foot ulcerations are one of the MC complications associated with Diabetes  Global annual incidence 6.3%  >50% of diabetic ulcers become infected & 20% of those w/ modera...

Diabetic Foot Exam CLINICAL SKILLS II AM&A FLEENOR, MMS, PA-C  Diabetic Foot Statistics  Diabetic foot ulcerations are one of the MC complications associated with Diabetes  Global annual incidence 6.3%  >50% of diabetic ulcers become infected & 20% of those w/ moderate to severe infection result in amputation  Nearly 85% of diabetes-related amputations are preceded by an ulceration  Regular foot exams can reduce amputation rates 45-85%  Pathogenesis of Ulceration  The MC pathway to ulceration:  Neuropathy (key precipitating factor) → Pedal Deformity → Trauma (typically repetitive microtrauma: Pressure, friction, & shearing forces on soft tissue)  Other risk factors  Previous ulceration/amputation  PAD/PVD  Foot Deformity  Peripheral Neuropathy  Poor glycemic control  Visual impairment  Nephropathy  Smoking ** Should be performed at every visit in patients with sensory loss, previous foot ulcers, or amputations Comprehensive Medical Evaluation & Assessment of Comorbidities: St&ards of Medical Care in Diabetes—2019. American Diabetes Association. Diabetes Care Jan 2019  1. Visual Inspection  Dermatologic  Skin status: Color, thickness, dryness, cracking  Sweating  Infection: Check between toes for fungal infection  Ulceration  Calluses/Blistering: Hemorrhage into callus?  Musculoskeletal  Deformity, e.g., claw toes, prominent metatarsal heads, Charcot joint  Muscle wasting (guttering between metatarsals)  1. Visual Inspection  Don’t forget Footwear (trauma)  Shoe gear  Are shoes wide & deep enough to accommodate feet/deformities?  Do shoes show excessive wear? Loss of protective padding?  Are shoes to short? (hint- pull out insole & look at the imprint of longest toe. Should have a finger length space to the end of insole)  Socks  Are they present? Worn out? Too constricting?  2. Screen for PAD  Check dorsalis pedis & posterior tibialis pulses  Again, inspect for physical signs of PAD  Hair loss, pallor/cyanosis, thinning of skin, ulceration, etc.  Check or refer for ABI if necessary  Signs & symptoms of vascular disease, absent pulses on exam  3. Neurologic/Protective Sensation  Sensation - Loss of protective sensation (LOPS) is a high risk factor for ulceration!  Recommended to perform 10g monofilament +1 of the following 4 tests  Vibration using 128-Hz tuning fork  Pinprick sensation  Ankle Reflexes  Vibration perception threshold (VPT)  10g Monofilament Exam 1. Patients should close their eyes while being tested 2. The sensation of pressure using the buckling 10-g monofilament should first be demonstrated to the patient on a proximal site (ie. upper arm, thigh) 3. The sites of the foot may then be examined by asking the patient to respond “yes” or “no” when asked whether the monofilament is being applied to the particular site 1. Areas of callus should always be avoided when testing for pressure perception.  3. Neurologic/Protective Sensation  Vibration using 128-Hz tuning fork  Vibratory sensation should be tested over the tip of the great toe bilaterally  Abnormal response - the patient loses vibratory sensation & the examiner still perceives it while holding the fork on the tip of the toe  Pinprick sensation  A disposable pin should be applied just proximal to the toenail on the dorsal surface of the hallux, with just enough pressure to deform the skin  Inability to perceive pinprick over either hallux would be regarded as an abnormal test result  Ankle Reflexes  Vibration perception threshold (VPT)  The biothesiometer is a handheld device that gives semiquantitative assessment of (VPT)  With the patient lying supine, the stylus of the instrument is placed over the dorsal hallux & the amplitude is increased until the patient can detect the vibration; the resulting number is known as the VPT  A mean of three readings is taken over each hallux. A VPT >25 V is regarded as abnormal Risk Classification & Follow-up