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The Diabetic Foot Exam DR AMY ROSS (FY2)What is this?OSCE EXAMINATION– what is expected INSPECTION CHARCOT’S FOOT PALPATION SENSATION MONOFILAMENT DIABETIC NEUROPATHY PROPRIOCEPTION REFLEXES FURTHER INVESTIGATIONSOSCE examination- hints and tips - be familiar with the monofilament tip & understand reasoning of why it is used. - have an understanding of what clinical signs you are looking for & why they might present in this type of patient. - useful tip – be aware of environment, could state would inspect the shoes to see if any stones/material that patient might not have been aware of due to sensory neuropathy. - have an awareness of variety of support services available for these patients and annual check ups… 3 “opathy’s”…OSCE CHECK LIST - https://geekymedics.com/wp-content/uploads/2020/09/OSCE-Checklist- Diabetic-Foot-Examination.pdfIntroduction 1. Wash hands 2. Introduce yourself to the patient 3. Confirm the patient’s name and date of birth. 4. Briefly explainwhat the examination will involve 5. Gain consent 6. Position the patient on the bed, with the head of the bed at45°. Important - ** ask patient if they are in any pain prior to examining **Assessing GAIT Speed: - reduced with advanced peripheral neuropathy. Stance: - broad based gait may be associated with advanced peripheral neuropathy to increase stability - increased risk of falls Steps: - high-stepping may indicate the presence of foot drop. Turning:- with peripheral neuropathy can find turning difficult - may look those down at feet whilst turningInspection of footwear Appropriate footwear - important for diabetic patients (impaired sensation and poor peripheral perfusion). Inappropriate footwear/foreign objects can lead to tissue injury +/- formation of diabetic foot ulcer. 1. Pattern of wear on insoles (asymmetrical wearing may indicate an abnormal gait). 2. Are shoes correct size for the patient? 3. Any foreign objects that could lead to injury?General Inspection– Entire foot (including the heels) Any ulcers? Check between Scars from Foot calluses – the toes! previous bypass abnormal gait or Hair loss surgery or healed poorly fitting ulcers footwear Missing limbs, toes or fingers Peripheral Peripheral pallor cyanosisCharcot’s Foot Charcot arthropathy v involves the progressive degeneration of a weight-bearing joint due to peripheral neuropathy. Typical features include: • Effusion • Distortion • Overlying erythema • Loss of joint function v Significant focus goes into preventative measures e.g. daily inspection and education The patient had noticed swelling ∼ 3 weeks without any known injury. X-ray- several fractures (arrowheads) & dislocation of the first metatarsal (arrow). This severe an injury is typically seen only after a high-energy trauma in patients without diabetesInspection is complete– what would you like to assess in palpation section?Palpation– temperature Using dorsal aspect of your hand - assess and comparetemperature: v In healthy patients- lower limbs should be symmetrically warm(adequate perfusion). v A cool and pale limb is suggestive of poor arterial perfusion.Pulses– what two main pulses would you like to check??Palpation– pulses Posterior tibialand dorsalis pedis pulses. Posterior tibial pulse Posterior tibial pulse located posterior to the medial malleolus of the tibia. Palpate the pulse to confirm if present and then compare pulse strength between the feet. Dorsalis pedis pulse located over the dorsum of the foot, lateral to the extensor hallucis longus ten, over the second and third cuneiform bones. Palpate the pulse to confirm if present and then compare to other side. Absence of peripheral pulses indicates peripheral vascular disease.Sensation- Monofilament Avoid pin prick testing - Test monofilament sensation on sternum. - With eyes closed, apply monofilament to each: pulp of the hallux. rd pulp of 3 digit. metatarsophalangeal joints 1/3/5. Ask the patient to report when they feel the monofilament touch. Hold against the skin for 1-2 seconds. Avoid calluses/scars à reduced level of sensation- not representativeMany different regimes “Say yes when you feel it” rather than “Can you feel this” Some areas not felt – at risk If all – high risk +++Diabetic Neuropathy Gloves and stocking neuropathy (not dermatomal) - tingling/ numbness/ walking on cotton wool sensation How monofilament works: Synthetic plastic monofilament – designed so that when applied to skin at 90 degree angle with just enough force to make it bend – this equals 10g load (standardised)Tuning for– vibration sensation Test vibration sense – loss of protective sensation (small vessel disease neural ischaemia) - involves the dorsal columns. - Ask the patient to close their eyes and to let you know both when they can feel vibration and when it stops. - Tap a 128 Hz tuning fork and place onto the patient’s sternum for initial check. Then grasp the ends – stop vibration. - Tap tuning fork again and place at IP joint. Determine if pt can identify when the vibration begins and when stops - If impaired at the IP joint, continue to assess more proximal joints (e.g. metatarsophalangeal joint of the big toe → ankle joint → knee joint) until the patient can identify. Proprioception (also known as joint position sense, involves the dorsal columns). 1. Start at IP joint of the big toe by holding the distal phalanx of the big toe by sides (avoid holding nail bed as patient can tell direction from the pressure). 2. Demonstrate movement “upwards” and “downwards” to patient with eyes open. you are moving their big toe up or down.nd state if 4. Move the big toe up or down 2-3 times in a random sequence. 5. If unable à continue by assessing more proximal joints (e.g. metatarsophalangeal joint of the big toe → ankle joint → knee joint). Reflexes Assess ankle-jerk reflex (S1) in each side. May be absent in advanced peripheral neuropathy – loss of afferent arc. Method 1 - Support their leg so that their hip is slightly abducted, the knee is flexed and the ankle is dorsiflexed. - 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 - Ask patient to kneel on a chair - Tap the Achille’s tendon with the tendon hammer and observe for a contraction in the gastrocnemius muscle with associated plantarflexion of the foot.Further investigations Bedside capillary blood glucose: if concern patient is hyperglycaemic or hypoglycaemic. Serum HbA1c: to assess blood glucose control over the past 3 months. Lower limb neurological examination: if diabetic foot examination reveals neurological deficits. Peripheral arterial examinationvenous examination: if diabetic foot examination suggested any signs Foot care advice:including regular podiatry input & appropriate footwear. Diabetic foot specialist/Podiatrist annual check.Thank you! 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