Medically Fit For Exams
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Diabetic foot screening and full examination

Introduce yourself, wash hands and check patient details

 

Explain the procedure and gain consent

 

General inspection

  • Inspect footwear
  • Is the patient using any walking aids or a wheelchair
  • Does the patient have obvious amputations
  • Ask about history of ulcers and amputations

 

Remove socks and inspect feet

  • Check in between toes and under heel
  • Colour
  • Swelling or Charcot joints
    • Hot, swollen, deformed joints
  • Dressings – remove bandages if possible
  • Ulcers
  • Callous
  • Excessive dry skin
  • Toe/partial foot amputation
  • Nail problems

 

Palpate feet

  • Temperature
  • Pulses – presence/absence and character (bounding?)
    • Dorsalis pedis (between first and second met base (further towards second met), halfway up foot)
    • Posterior tibial (behind and below medial malleolus)
    • Popliteal
    • Femoral

 

Sensory assessment

 

Screening

  • Using either monofilament or tuning fork
  • 10g monofilament assessment of light touch, single touch 1-2 sec to bend filament at least 5 non callused areas pressure areas per foot
  • First show the patient that the monofilament is not sharp by performing the test on the back of your hand and then on the patient’s forearm
  • Inform the patient that you will be testing each foot with their eyes closed and they have to say yes each time they feel the monofilament touch their foot
  • There are 5 areas tested on each foot
    • Apex of the 1st and 3rd toes
    • The 1st, 3rd and 5th metatarsal heads
    • These tests are carried out in a random fashion with the monofilament at a 90° angle to the foot.
  • The monofilament showed be depressed with enough force to cause a bend in the monofilament and should be in contact with the skin for between 1 and 2 seconds
  • The monofilament should not be allowed to slide across the surface of the skin and areas of callus or any breaks in the skin should be avoided.
  • If the patient can not feel more than 8/10 of the tested sites then they can be diagnosed as having PDN and this can put them at risk of developing a diabetic foot ulcer

 

Full assessment

  • Monofilament test as above
  • Sharpness vs dullness test
    • As above, but with a neurotip (sharp and blunt ends)
    • Demonstrate the difference to the patient first on the forearm or sternum
  • Vibration testing
    • Explain to the patient and demonstrate the different between vibration and still on their wrist or sternum
    • Vibrate tuning fork by tapping it, and shielding with hand to prevent the patient from hearing
    • Place on bony prominences
    • Ask to say if it is vibrating or dull
  • Proprioception
    • Explain, and demonstrate by moving the patient’s hallux up and down
    • Move their hallux up and down and ask them to say ‘up’ or ‘down’ appropriately

 

Risk classification

  • Low risk
    • No risk factors
    • Present pulses, normal sensation, no ulcers or ulcer history, no deformity
  • Moderate risk
    • One risk factor
    • One of: Loss of sensation, absent pulses, previous vascular surgery, foot deformity and callus
  • High risk
    • Previous ulcer
    • Previous amputation
    • On renal replacement therapy
    • Absent pulses and sensory loss
    • Callus plus one of: sensory loss, deformity, absent pulses

 

Management plan

  • Low risk:
    • Annual screening
    • Self-management
    • Written/verbal education + recognition of possibility of progression + emergency contact numbers
    • Access to a podiatrist if necessary
  • Moderate risk:
    • Refer to foot protection service (podiatry run) for yearly checks
    • Review every 3-6 months
    • Written/verbal education + emergency contact numbers
  • High risk:
    • Annual assessment by podiatrist, with tailored management plan
    • Review every 1-2 months, every 1-2 weeks if immediate concern
    • Referral for specialist service if/when required
    • Written/verbal education + emergency contact numbers

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