11-13/11/2009Step By Step Improving Diabetes Foot Care in Egypt
Foot screening
Why
11-13/11/2009Step By Step Improving Diabetes Foot Care in Egypt
• Five cornerstones of the management of thediabetic foot
1. Regular inspection and examination of the foot.
2.Identification of the foot at risk.
3.Education of patient, family and healthcare providers.
4.Appropriate footwear.
5.Treatment of non ulcerative pathology
Step By Step Improving Diabetes Foot Care in Egypt11-13/11/2009
Five cornerstones of the management of the diabetic foot
Five cornerstones of the managementof the diabetic foot
1. Regular inspection and examination of the foot.
2.Identification of the foot at risk.
3.Education of patient, family and healthcare providers.
4.Appropriate footwear.
5.Treatment of non ulcerative pathology
Step By Step Improving Diabetes Foot Care in Egypt11-13/11/2009
Why
11-13/11/2009Step By Step Improving Diabetes Foot Care in Egypt
• Five cornerstones of the management of thediabetic foot
• Risk categorization system
11-13/11/2009Step By Step Improving Diabetes Foot Care in Egypt
category Risk profile Check up frequency
0 no sensory neuropathy Once a year
1 sensory neuropathy Once every 6 months
2sensory neuropathy and signs of
peripheral vascular disease and/or foot deformities.
Once every 3 months
3 previous ulcer Once every 1-3
months
Risk categorization system
11-13/11/2009Step By Step Improving Diabetes Foot Care in Egypt
How
Regular inspection and examination of the foot
Step By Step Improving Diabetes Foot Care in Egypt
• All diabetic patients should be examined at first presentation then at least once a year
• Patients with risk factors should be examined every 1-6 months
• Absent symptoms does not mean that the feet are healthy
• Examine the patient on lying down and standing up
• Shoe and socks should be inspected
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Foot examination
Step By Step Improving Diabetes Foot Care in Egypt
1. Nails
2. Foot deformity
3. Skin condition
4. Vascular assessment
5. Neurological assessment
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Step By Step Improving Diabetes Foot Care in Egypt
Does your patient have neuropathy?11-13/11/2009
PROF / MANAL TARSHOBYP R O F O F I N T E R N A L M E D I C I N E
D I A B E T E S A N D E N D O C R I N O L O G Y U N I T
D I A B E T I C F O O T T E A M
M A N S O U R A U N I V E R S I T Y
Step By Step Improving Diabetes Foot Care in Egypt
How to diagnose diabetic neuropathy
11-13/11/2009
Clinical Assessment
Step By Step Improving Diabetes Foot Care in Egypt
Are your feet numb
Burning pain
Feet sensitive to touch
Muscle cramp
Can you tell hot from cold water
Have you had an ulcer
Dr diagnosed neuropathy
Do you feel weak
Symptom worse at night
Legs hurt when you walk
Prickling feeling
Able to sense feet when walking
Bed covers hurt your skin
Your skin crack open
Unsteadiness
Previous amputation
Feldman, Diabetes care,1994
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History
Clinical Assessment
Step By Step Improving Diabetes Foot Care in Egypt
Remember
50% has no symptoms
Review other causes of neuropathy (10%)
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Clinical Assessment
Step By Step Improving Diabetes Foot Care in Egypt
Remember
Review diabetes history, management
Daily glycemic records, previous A1c
Review medical history
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Physical Examination
Step By Step Improving Diabetes Foot Care in Egypt
• Inspection
• Vibration sense Tuning fork 128
• Reduced protective sensation such as pressure, hot and cold, pain
• Sharp, dull, light touch
• Deep tendon reflex
11-13/11/2009
Physical Examination
Step By Step Improving Diabetes Foot Care in Egypt
• Inspection• Vibration sense Tuning fork 128
• Reduced protective sensation such as pressure, hot and cold, pain
• Sharp, dull, light touch
• Deep tendon reflex
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Inspection
Step By Step Improving Diabetes Foot Care in Egypt
• Muscle atrophy• Intrinsic minus foot
• Dry skin
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Inspection
11-13/11/2009Step By Step Improving Diabetes Foot Care in Egypt
Dilated Veins
Warm Foot
Neuropathy AssessmentWhat to use
11-13/11/2009Step By Step Improving Diabetes Foot Care in Egypt
Physical Examination
Step By Step Improving Diabetes Foot Care in Egypt
• Inspection
• Vibration sense • Tuning fork 128
• neurothesiometer
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Vibration Sense
•Tuning fork is held against a bony prominence:• Medial aspect 1st MTP Joint• Plantar Hallux• Med/Lat Malleolus
•Patients should be reminded that it is the vibration they are required to detect not the sound
•128
•Perpedicular
•Constant pressure
Step By Step Improving Diabetes Foot Care in Egypt 11-13/11/2009
Step By Step Improving Diabetes Foot Care in Egypt 11-13/11/2009
NEUROTHESIOMETER
•Vibration threshold is strongly linked with age
•Males have slightly higher thresholds than females Age 15 35 55
Males 8.8 volts 12.9 volts 19.9 volts
Females 8.3 volts 10.8 volts 14.6 volts
11-13/11/2009Step By Step Improving Diabetes Foot Care in Egypt
NEUROTHESIOMETER
•At the distal pulp of the hallux, over bony prominence
•Voltage is increased until the patient can perceive vibration
11-13/11/2009Step By Step Improving Diabetes Foot Care in Egypt
Foot ulcer risk increased by 5.6% per volt
Abott, Diabetes care, 1998
Physical Examination
Step By Step Improving Diabetes Foot Care in Egypt
• Inspection
• Vibration sense
• Reduced protective sensation • pressure
• hot and cold
• pain
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MONOFILAMENTS
Which monofilament ?
11-13/11/2009Step By Step Improving Diabetes Foot Care in Egypt
• 10 g, 1g
• Calibrated
HOW TO USE IT?
11-13/11/2009Step By Step Improving Diabetes Foot Care in Egypt
•Teach your patient•Perpendicular•Until bended•Close his eyes•Do you feel it•Where•3 times/ site
11-13/11/2009Step By Step Improving Diabetes Foot Care in Egypt
How many sites to be tested?
11-13/11/2009Step By Step Improving Diabetes Foot Care in Egypt
How many sites to be tested?
MONOFILAMENTS
How many lost sites to diagnose LOPS
1
Step By Step Improving Diabetes Foot Care in Egypt 11-13/11/2009
Monofilament Failure
Step By Step Improving Diabetes Foot Care in Egypt
• Application on area with callus, scar, ulcer or necrotic tissue
• Require frequent replacement
• Repetitive loading?
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TEMPERATURE TESTING
Step By Step Improving Diabetes Foot Care in Egypt
• Two test tubes, hot/cold.
• Therm-tip
• Subjective, crude tests
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SUPERFICIAL PAIN TEST
• Neuro - tip• Areas tested• Patient response• Significance
Step By Step Improving Diabetes Foot Care in Egypt 11-13/11/2009
Physical Examination
Step By Step Improving Diabetes Foot Care in Egypt
• Inspection
• Vibration sense
• Reduced protective sensation
• Sharp, dull, light touch
11-13/11/2009
LIGHT TOUCH TEST
Wisp of cotton wool Subjective Can be painful if neuropathy
exists
Step By Step Improving Diabetes Foot Care in Egypt 11-13/11/2009
Step By Step Improving Diabetes Foot Care in Egypt 11-13/11/2009
Physical Examination
Step By Step Improving Diabetes Foot Care in Egypt
• Inspection
• Vibration sense Tuning fork 128
• Reduced protective sensation such as pressure, hot and cold, pain
• Sharp, dull, light touch
• Deep tendon reflex
11-13/11/2009
Deep tendon reflex
Step By Step Improving Diabetes Foot Care in Egypt 11-13/11/2009
11-13/11/2009Step By Step Improving Diabetes Foot Care in Egypt
category Risk profile Check up frequency
0 no sensory neuropathy Once a year
1 sensory neuropathy Once every 6 months
2sensory neuropathy and signs of
peripheral vascular disease and/or foot deformities.
Once every 3 months
3 previous ulcer Once every 1-3
months
Risk categorization system
11-13/11/2009Step By Step Improving Diabetes Foot Care in Egypt
Thank you