Diabetic Foot Examination

Question 1

What are the stages of the Diabetic Foot Examination?

Answer 1

1. Intro
2. Inspection
3. Palpation
4. Vascular Examination
5. Neurological Examination
6. Closing the Exam

Question 2

What is specifically asked in the intro of the diabetic foot exam?

Answer 2

Before commencing, ask the patient if they have any pain in their ankles or feet. Both legs should be exposed from the knee down to the feet.

Question 3

Describe the Inspection stage of the DFE?

Answer 3

Inspect the patient’s gait
• Inspect the patient’s shoes for signs of uneven wear, presence of foreign objects
• Inspect the skin of the patient’s feet for:
• trophic changes - hairlessness, pallor, decreased sweating (autonomic dysfunction), dry cracked skin
• rubor at pressure points
• skin ulceration
• diabetic dermopathy (brown macules) over shins
• infection: cellulitis (erythema, swelling), gangrene
• webspaces: cracked, infected, ulcers, maceration
• toe nails: dystrophic, in-growing toenails, paronychia, onychomycosis
• Inspect the feet for deformities, intrinsic muscle wasting (clawed, hammer toes), pes planus (flat foot) or pes cavus (high arch)

Question 4

What are the brief areas of the DFE inspection?

Answer 4

Gait
Shoes
Skin on patient's feet
Toe Nails
Looking for deformities, muscle wasting, pes planus, or pes cavus

Question 5

Describe the palpation stage of the DFE?

Answer 5

Palpate the bones and joints of the ankle and foot for swelling and tenderness. Watch the patients face throughout and ask them to let you know if they experience any discomfort.

Question 6

Describe the vascular exam stage of the DFE?

Answer 6

Temperature. Use the back of your hand, compare shins to feet bilaterally. Note: temperature should decrease slightly as you move distally
 • Pulses:
• femoral (omit in the OSCE) 
• popliteal (if foot pulses absent) 
• posterior tibial 
• dorsalis pedis 
• Capillary refill

Question 7

Describe the neurological exam stage of the DFE?

Answer 7

• Reflexes:
• ankle jerk
• Sensation:
• Light touch (with cotton wool).
• Pressure. Apply a 10g monofilament on the patient’s hand or sternum so the patient knows what to expect. Ask the patient to close their eyes and apply the monofilament to the pulp of the hallux and to the 1st, 3rd and 5th metatarsal heads. Apply the monofilament perpendicular to the skin surface and apply sufficient force to cause the filament to bend or buckle. Do not allow the filament to slide across the skin or make repetitive contact at the test site. The total duration of the approach, skin contact, and removal of the filament should be approximately 2 seconds.
• pin prick (omit in the OSCE)
• temperature (omit in the OSCE)
• proprioception
• vibration (1st modality to lose, 128 Hz tuning fork), if absent at 1st MTPJ, move more proximally