COMPREHENSIVE DIABETIC FOOT EXAM (CDFE) WITH VERIFIED SOLUTIONS

Why is it important to examine the feet of diabetic patients? To identify risks of, and to prevent neuropathy and other diabetic complications What is neuropathy? Disease or dysfunction of one or more peripheral nerves, typically causing numbness or weakness. Neuropathy is a complication of uncontrolled diabetes. This can lead to a patient that can't feel their feet. - Tingling/Burning - Numbness/ Loss of feeling - Improper blood flow/circulation What are some risk factors for ulcers and amputations? - Poor glycemic control - Peripheral neuropathy with LOPS (loss of protective sensation) - Cigarette smoking - Foot deformities (or history of) - Peripheral Arterial Disease (PAD) --> poor circulation - Amputation - Visual impairment - CKD - Nephropathy How often do we perform CDFEs on new patients, or patients without evidence of neuropathy? - Type 2 diabetics? - Type 1 diabetics? - Type 2 diabetics: annually - Type 1 diabetics: 5 years after diagnosis, then annually How often do we perform CDFEs on patients with evidence of sensory loss, prior ulceration, or amputation? They should have their feet inspected at every visit What are the general steps? * Wash hands before touching patient* 1. Patient interview 2. General inspection 3. Neurological exam 4. Vascular assessment What are the steps of the patient interview? (and examples of things you would want to ask) - Past history - Neuropathic symptoms - Vascular symptoms - Other diabetic complications? "How long have you been diagnosed with diabetes? How often do you check your blood sugar? What kind of numbers have you been getting? Do you use nicotine products? Tell me about any issues with your feet." What are things you would inspect/palpate? - Shoes/socks - Dermatologic - Ulceration, Calluses, Erythema, Nail dystrophy, Paronychia - Musculoskeletal - Deformities (claw toe, hammer toe, charcot joint), Muscle-wasting What are some dermatological findings you are looking for? Callouses Ulcers Tinea pedis Paronychia What are some foot deformities you are looking for? Hammer toe Claw toe Charcot Arthropathy Foot drop What tools do you use when conducting the neurological exam? Monofilament test 128-Hz tuning fork (vibration) Rubber hammer (for checking ankle reflexes) [pinprick sensation & neurothesiometer - know for exam, not OSCE] Pinprick and Vibration Perception Threshold [Know for written exam, not OSCE] - Pinprick sensation - On top of food; 3 locations (beneath nail of big toe, middle toe, and pinkie toe) - Vibration Perception Threshold (VPT) using a Neurothesiometer - Voltage increased until patient feels it; [>25 = abnormal] How do you perform the monofilament test? 1. Clean monofilament with alcohol swab 2. Demonstrate on top of hand first 3. Patient should close eyes 4. Touch monofilament to 5 sites on bottom of EACH foot, avoiding calluses or wounds 1st, 3rd, 5th metatarsal heads 1st and 3rd/5th toe How do you use the 128-Hz Tuning Fork? Test over the bony prominence (at top or side) of the great toe bilaterally 1. Tap top of tuning fork on your hand 2. Hold base of fork and touch to great toe 3. "Tell me when you feel the vibrations go away" If they stop feeling it 8+ seconds early, possible neuropathy How do you test ankle reflexes? 1. Stretch achilles tendon until ankle is in a neutral/relaxed position 2. Helpful to rest your fingers slightly under the patient's toes while you do it (to feel reflex easier) 3. Tap achilles tendon lightly with rubber hammer 4. PERFORM ON BOTH FEET How do we perform vascular assessments? What do we check? - Foot pulses - Ankle brachial index (if indicated) How do we palpate foot/ankle pulses? Where do we find them? - Dorsalis pedis pulse - top of foot between big toe and 2nd toe - Posterior tibial pulse - in groove between bony prominence of ankle and achilles tendon [Tip: Use 2-3 fingers; not thumb; 2+ is normal] What is Ankle Brachial Pressure Index? How do you test this? What does a low number indicate? A quick, noninvasive way to check for Peripheral Artery Disease (PAD) It compares the BP measured at the ankle with the BP measured at the arm A low ABI number can indicate blockage in the arteries in the legs Which patients need an ABI (ankle-brachial index) and a possible vascular referral? - Diabetic patients with absent pulses or signs/symptoms of vascular disease (claudication, non-healing ulcers, rest pain) [REFERRAL] - Diabetic patients > 50 years old - Diabetic patients < 50 years old with multiple risk factors for PAD - Repeat normal tests every 5 years Risk classification based on the comprehensive foot examination (chart) Includes risk category, definition, treatment recommendations, suggested follow-up See Chart