Diabetic foot physical examination: Difference between revisions
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====Neuropathy Assessment==== | ====Neuropathy Assessment==== | ||
*Using the [[neuropathy]] [[symptoms]] score (NSS) and [[neuropathy]] disability score (NDS) is helpful in [[physical examination]] of [[patients]] with [[diabetic foot]].<ref name="pmid12421436">{{cite journal| author=Meijer JW, Smit AJ, Sonderen EV, Groothoff JW, Eisma WH, Links TP| title=Symptom scoring systems to diagnose distal polyneuropathy in diabetes: the Diabetic Neuropathy Symptom score. | journal=Diabet Med | year= 2002 | volume= 19 | issue= 11 | pages= 962-5 | pmid=12421436 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12421436 }} </ref><ref name="pmid15317601">{{cite journal| author=Daousi C, MacFarlane IA, Woodward A, Nurmikko TJ, Bundred PE, Benbow SJ| title=Chronic painful peripheral neuropathy in an urban community: a controlled comparison of people with and without diabetes. | journal=Diabet Med | year= 2004 | volume= 21 | issue= 9 | pages= 976-82 | pmid=15317601 | doi=10.1111/j.1464-5491.2004.01271.x | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15317601 }} </ref><ref name="pmid22172474">{{cite journal| author=Lepäntalo M, Apelqvist J, Setacci C, Ricco JB, de Donato G, Becker F | display-authors=etal| title=Chapter V: Diabetic foot. | journal=Eur J Vasc Endovasc Surg | year= 2011 | volume= 42 Suppl 2 | issue= | pages= S60-74 | pmid=22172474 | doi=10.1016/S1078-5884(11)60012-9 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22172474 }} </ref> | *Using the [[neuropathy]] [[symptoms]] score (NSS) and [[neuropathy]] disability score (NDS) is helpful in [[physical examination]] of [[patients]] with [[diabetic foot]].<ref name="pmid12421436">{{cite journal| author=Meijer JW, Smit AJ, Sonderen EV, Groothoff JW, Eisma WH, Links TP| title=Symptom scoring systems to diagnose distal polyneuropathy in diabetes: the Diabetic Neuropathy Symptom score. | journal=Diabet Med | year= 2002 | volume= 19 | issue= 11 | pages= 962-5 | pmid=12421436 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12421436 }} </ref><ref name="pmid15317601">{{cite journal| author=Daousi C, MacFarlane IA, Woodward A, Nurmikko TJ, Bundred PE, Benbow SJ| title=Chronic painful peripheral neuropathy in an urban community: a controlled comparison of people with and without diabetes. | journal=Diabet Med | year= 2004 | volume= 21 | issue= 9 | pages= 976-82 | pmid=15317601 | doi=10.1111/j.1464-5491.2004.01271.x | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15317601 }} </ref><ref name="pmid22172474">{{cite journal| author=Lepäntalo M, Apelqvist J, Setacci C, Ricco JB, de Donato G, Becker F | display-authors=etal| title=Chapter V: Diabetic foot. | journal=Eur J Vasc Endovasc Surg | year= 2011 | volume= 42 Suppl 2 | issue= | pages= S60-74 | pmid=22172474 | doi=10.1016/S1078-5884(11)60012-9 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22172474 }} </ref> | ||
*Findings that favor the [[diagnosis]] of [[neuropathy|sensory neuropathy]]: | *Findings that favor the [[diagnosis]] of [[neuropathy|sensory neuropathy]]:<ref name="pmid9531915">{{cite journal| author=Armstrong DG, Lavery LA| title=Diabetic foot ulcers: prevention, diagnosis and classification. | journal=Am Fam Physician | year= 1998 | volume= 57 | issue= 6 | pages= 1325-32, 1337-8 | pmid=9531915 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9531915 }} </ref><ref name="pmid7729300">{{cite journal| author=McNeely MJ, Boyko EJ, Ahroni JH, Stensel VL, Reiber GE, Smith DG | display-authors=etal| title=The independent contributions of diabetic neuropathy and vasculopathy in foot ulceration. How great are the risks? | journal=Diabetes Care | year= 1995 | volume= 18 | issue= 2 | pages= 216-9 | pmid=7729300 | doi=10.2337/diacare.18.2.216 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=7729300 }} </ref> | ||
**Impaired [[vibration]] perception | **Impaired [[vibration]] and [[pressure]] perception | ||
**Impaired [[Proprioception|position sense]] | |||
**Depressed [[Tendon reflex|tendon reflexes]] | **Depressed [[Tendon reflex|tendon reflexes]] | ||
*Dull, crushing or cramp-like [[pain]] in the [[bone|bones]] of the [[feet]] | **Dull, crushing or cramp-like [[pain]] in the [[bone|bones]] of the [[feet]] | ||
*Sensory [[ataxia]] | **Sensory [[ataxia]] | ||
*Shortening of the [[achilles tendon]] | **Shortening of the [[achilles tendon]] | ||
*Abnormal thresholds for warm thermal perception | **Abnormal thresholds for warm thermal perception | ||
*Decreased neurovascular function | **Decreased neurovascular function | ||
===Extremities=== | ===Extremities=== | ||
====Inspection==== | ====Inspection==== | ||
Revision as of 14:49, 5 July 2021
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Diabetic foot physical examination On the Web |
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Anahita Deylamsalehi, M.D.[2] Vishnu Vardhan Serla M.B.B.S. [3]
Overview
Physical Examination
Appearance of the Patient
- Patients with diabetic foot ulcer could appear ill if ulcers are severe or infected.
Vital Signs
- ±Fever (Based on the infection severity can present as high or low grade fever)
- Hypothermia or hyperthermia may be present
- Tachycardia
- Low blood pressure could be seen in septic patients
Skin
- Skin examination of patients with diabetic foot is usually normal, except for the foot skin.
HEENT
- HEENT examination of patients with diabetic foot is usually normal.
Neck
- Neck examination of patients with diabetic foot is usually normal.
Lungs
- Pulmonary examination of patients with diabetic foot is usually normal.
Heart
- Cardiovascular examination of patients with diabetic foot is usually normal.
Abdomen
- Abdominal examination of patients with diabetic foot is usually normal.
Back
- Back examination of patients with diabetic foot is usually normal.
Genitourinary
- Genitourinary examination of patients with diabetic foot is usually normal.
Neuromuscular
- Neuromuscular examination of patients with diabetic foot is usually normal, except in their foot. Examine their foot for the following:
- Motor examination
- Tone
- Power
- Reflexes
- Sensory examination
- Vibration
- Joint position sense
- Motor examination
Neuropathy Assessment
- Using the neuropathy symptoms score (NSS) and neuropathy disability score (NDS) is helpful in physical examination of patients with diabetic foot.[1][2][3]
- Findings that favor the diagnosis of sensory neuropathy:[4][5]
- Impaired vibration and pressure perception
- Impaired position sense
- Depressed tendon reflexes
- Dull, crushing or cramp-like pain in the bones of the feet
- Sensory ataxia
- Shortening of the achilles tendon
- Abnormal thresholds for warm thermal perception
- Decreased neurovascular function
Extremities
Inspection
The following list is a summary of possible findings in diabetic foot inspection:[3][6][7]
- Peeling skin, maceration, fissuring between toes
- Dilated or varicose veins
- Scar
- Sinuses
- Shiny skin
- Decreased hair distribution
- Areas of pigmentation or discoloration
- Ulcers
- Ulcers in the areas under pressure such as base of the toe or the fifth metatarsus and posterior aspect of heel.
- Brittle or broken nail
- Infection
- Such as fungal infection
- Presence of pus or at least two of the following is indicative of infection:
- Redness
- Pain
- Warmth
- Delayed wound healing
- Swelling
- Bad odor
- In some cases unroofing a small scar demonstrates a deeper infected abscesses. In the other word, evaluating an ulcer for infection must be done after debridement.
- Foot deformities such as charcot foot and hammer toe
- Pink skin
- Even in ischemic settings due to arteriovenous shunting.
Palpation
The following is a list of recommended examinations in a diabetic foot patients:[3]
- Temperature
- Increased temperature could be due to deep vein thrombosis while decreased temperature could be an ischemia presentation.
- Due to arteriovenous shunting the involved area may feel warm even in presence of ischemia.
- Tenderness (squeeze calf muscle and achilles tendon for tenderness)
- Pulses such as dorsalis pedis and posterior tibial pulses
- Although even when both dorsalis pedis and posterior tibial pulses are present, low perfusion can not be excluded.
- Note that dorsalis pedis and posterior tibial pulses are absent in 8% and 3% of normal population, respectively.
- Capillary filling time (venous refilling > 5s)
- Muscle strength and tone
- Check ankle brachial index (ABI)
- Pinprick discrimination and tactile sensation test (use a cotton wool to examine)
- Vibration test (use a 128 Hz-tuning fork)
- Pressure perception test (use a 10-gram (5.07) Semmes––Weinstein monofilament)
- Quantitative sensory testing and autonomic testing
Video: Physical Examination Diabetes
{{#ev:youtube|715j6zRZHaA}}
Image: Diabetic Foot Ulcer
References
- ↑ Meijer JW, Smit AJ, Sonderen EV, Groothoff JW, Eisma WH, Links TP (2002). "Symptom scoring systems to diagnose distal polyneuropathy in diabetes: the Diabetic Neuropathy Symptom score". Diabet Med. 19 (11): 962–5. PMID 12421436.
- ↑ Daousi C, MacFarlane IA, Woodward A, Nurmikko TJ, Bundred PE, Benbow SJ (2004). "Chronic painful peripheral neuropathy in an urban community: a controlled comparison of people with and without diabetes". Diabet Med. 21 (9): 976–82. doi:10.1111/j.1464-5491.2004.01271.x. PMID 15317601.
- ↑ 3.0 3.1 3.2 Lepäntalo M, Apelqvist J, Setacci C, Ricco JB, de Donato G, Becker F; et al. (2011). "Chapter V: Diabetic foot". Eur J Vasc Endovasc Surg. 42 Suppl 2: S60–74. doi:10.1016/S1078-5884(11)60012-9. PMID 22172474.
- ↑ Armstrong DG, Lavery LA (1998). "Diabetic foot ulcers: prevention, diagnosis and classification". Am Fam Physician. 57 (6): 1325–32, 1337–8. PMID 9531915.
- ↑ McNeely MJ, Boyko EJ, Ahroni JH, Stensel VL, Reiber GE, Smith DG; et al. (1995). "The independent contributions of diabetic neuropathy and vasculopathy in foot ulceration. How great are the risks?". Diabetes Care. 18 (2): 216–9. doi:10.2337/diacare.18.2.216. PMID 7729300.
- ↑ Wagner, F William (1987). "The Diabetic Foot". Orthopedics. 10 (1): 163–172. doi:10.3928/0147-7447-19870101-28. ISSN 0147-7447.
- ↑ Kalish, Jeffrey; Hamdan, Allen (2010). "Management of diabetic foot problems". Journal of Vascular Surgery. 51 (2): 476–486. doi:10.1016/j.jvs.2009.08.043. ISSN 0741-5214.