Diabetic foot physical examination: Difference between revisions
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==Overview== | ==Overview== | ||
[[Patients]] with [[diabetic foot]] [[ulcer]] could appear ill if [[ulcers]] are severe or [[infection|infected]]. In severe and [[Chronic (medical)|chronic]] [[infection|infected]] [[ulcers]] [[patients]] may have [[fever]], [[tachycardia]] and low [[blood pressure]]. [[Neuromuscular junction|Neuromuscular]] [[physical examination|examination]] of [[patients]] with [[diabetic foot]] is usually normal, except in their [[foot]]. Altered motor tone, [[Neurological examination|reflexes]] and sensation is expected in these [[patients]]. [[Neuropathy]] [[symptoms]] score (NSS) and [[neuropathy]] disability score (NDS) are helpful in neuropathy assessment of [[patients]] with [[diabetic foot]]. Findings such as impaired [[vibration]] and [[pressure]] perception, [[Proprioception|position sense]] and thresholds for warm thermal perception favor the [[diagnosis]] of [[neuropathy|sensory neuropathy]]. It is critical to check the [[Limb (anatomy)|extremities]] for findings such as [[ulcers]], peeling [[skin]], dilated or [[varicose veins]], shiny [[skin]] with reduced [[hair]] distribution and broken [[nail]] while examining [[diabetic foot]]. Moreover [[infection]] possibility should be evaluated. Findings such as [[pus]], [[erythema]], Warmth, [[induration]] and bad [[odor]] suggest the presence of [[infection]]. In some cases unroofing a small [[scar]] demonstrates a deeper [[infection|infected]] [[abscesses]]. In the other word, evaluating an [[ulcer]] for [[infection]] must be done after debridement. Other necessary [[physical examinations]] in these [[patients]] are checking the [[capillary]] filling time, [[Peripheral arterial disease screening|ankle brachial index]], tactile and vibration [[sensation]] and [[pressure]] perception. | |||
==Physical Examination== | ==Physical Examination== |
Revision as of 20:38, 14 July 2021
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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
Patients with diabetic foot ulcer could appear ill if ulcers are severe or infected. In severe and chronic infected ulcers patients may have fever, tachycardia and low blood pressure. Neuromuscular examination of patients with diabetic foot is usually normal, except in their foot. Altered motor tone, reflexes and sensation is expected in these patients. Neuropathy symptoms score (NSS) and neuropathy disability score (NDS) are helpful in neuropathy assessment of patients with diabetic foot. Findings such as impaired vibration and pressure perception, position sense and thresholds for warm thermal perception favor the diagnosis of sensory neuropathy. It is critical to check the extremities for findings such as ulcers, peeling skin, dilated or varicose veins, shiny skin with reduced hair distribution and broken nail while examining diabetic foot. Moreover infection possibility should be evaluated. Findings such as pus, erythema, Warmth, induration and bad odor suggest the presence of infection. 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. Other necessary physical examinations in these patients are checking the capillary filling time, ankle brachial index, tactile and vibration sensation and pressure perception.
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) are 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][8][9][10]
- 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 (thick, opaque to white or sanguineous secretion) or at least two of the following is indicative of infection:
- Redness (Erythema)
- Pain and local tenderness
- Warmth
- Delayed wound healing
- Swelling or induration
- 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.
- The following are some of the findings that indicate a limb threatening infection:
- Cellulitis extension more than 2 cm from the ulcer's margin
- Deep abscesses
- Osteomyelitis
- Severe ischemia
- 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][5][11]
- 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)
- Single most practical method to assess risks for diabetic foot such as neuropathy
- Quantitative sensory testing and autonomic testing
- Probing
- Using a blunted sterile probe will help physicians to determine ulcer's margins, sinus tract development and involvement of tendons, bones or joints.
- Positive probe-to-bone is strongly correlated with osteomyelitis.
Video: Physical Examination Diabetes
{{#ev:youtube|715j6zRZHaA}}
Image: Diabetic Foot Ulcer
![Diabetic foot ulcer](/images/d/d0/Diabetic_foot_ulcer.jpg)
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.
- ↑ 5.0 5.1 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.
- ↑ Caputo GM, Cavanagh PR, Ulbrecht JS, Gibbons GW, Karchmer AW (1994). "Assessment and management of foot disease in patients with diabetes". N Engl J Med. 331 (13): 854–60. doi:10.1056/NEJM199409293311307. PMID 7848417.
- ↑ Wukich DK, Armstrong DG, Attinger CE, Boulton AJ, Burns PR, Frykberg RG; et al. (2013). "Inpatient management of diabetic foot disorders: a clinical guide". Diabetes Care. 36 (9): 2862–71. doi:10.2337/dc12-2712. PMC 3747877. PMID 23970716.
- ↑ Lipsky BA, Berendt AR, Cornia PB, Pile JC, Peters EJ, Armstrong DG; et al. (2012). "2012 Infectious Diseases Society of America clinical practice guideline for the diagnosis and treatment of diabetic foot infections". Clin Infect Dis. 54 (12): e132–73. doi:10.1093/cid/cis346. PMID 22619242.
- ↑ Grayson ML, Gibbons GW, Balogh K, Levin E, Karchmer AW (1995). "Probing to bone in infected pedal ulcers. A clinical sign of underlying osteomyelitis in diabetic patients". JAMA. 273 (9): 721–3. PMID 7853630.