Diabetic foot examination

Introduction

• Wash hands
• Introduce self
• Ask Patient’s name, DOB and what they like to be called
• Explain examination and obtain consent
• Expose feet

Inspection

• General: gait, shoes (flat heel, pattern of wear), amputations 
• Skin: vascular insufficiency (hairlessness, pallor), rubor/corns/callus at pressure points, texture, fissures, skin breaks/lesions/ulcers, diabetic dermopathy, infection (swelling, erythema, gangrene, cellulitis), oedema, venous eczema/lipodermatosclerosis
• Nails: dystrophy, ingrown nails
• Webspaces: cracking, ulcers, maceration, infections
• Deformity: clawed toes, bony prominences, Charcot joints (joint swelling with collapse of medial longitudinal arch – due to loss of protective pain sensation) 

Trophic changes with bilateral callous formation and early ulceration

Charcot arthropathy

Arteriopathy assessment

• Temperature: use dorsum of each hand to feel up legs
• Pulses: femoral, popliteal, posterior tibial, dorsalis pedis
• Capillary refill (should be <2 seconds)

A patient presents to ED with chest pain and this trace. What would you do?

Interpretation management

Covered in OSCE Stations

Neuropathy assessment

• Sensory: show patient how each feels on sternum before and ask them to close their eyes
• 10g monofilament: fully extend the monofilament and press with enough force to make it bend. First let patient feel the sensation on their sternum, then ask them to close their eyes and tell you when they feel you touch their feet. Test sensation in multiple places, e.g. hallux and metatarsal heads.
• 128Hz Tuning fork: use your fingers to twang prongs and hold circular base on the patient’s joint. First let patient feel the sensation on their sternum, then ask them to close their eyes and tell you when they feel a vibration on their feet and when they feel it stop (stop the vibration yourself by gripping the prongs). Start over first MTP joint and move to proximal joints if the patient cannot feel it.
• Proprioception: hold the distal phalanx of the big toe with a finger on each side (while stabilising the proximal phalanx with your other hand). Flex and extend the joint with the patient watching these movements and then ask them to close their eyes. Wiggle the distal phalanx up and down a few times, then stop and ask the patient if their toe is up or down. If they cannot tell, test more proximal joints in succession until they can. 
• Motor: muscle wasting, pes planus, pes cavus, Charcot joints
• Reflexes: ankle jerk
• Autonomic: sweaty, dry, cracked skin

To complete  

• Thank patient and restore clothing
• ‘To complete my examination, I would perform a full neurovascular examination.’ 
• Summarise and suggest further investigations you would consider after a full history, for example:
  • ABPI
  • Doppler arterial pulses
  • Blood glucose
  • HbA1C

Ulcer comparison table

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Test your knowledge

Other than optimising glycaemic control, what is the management for the diabetic foot?

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What is the target HbA1C for patients with type 2 diabetes?

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How would you describe an ulcer after you note one on clinical examination?

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Now a station

1. Diabetic foot exam
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