Internal Medicine-Examination of a Diabetic foot

Begin with inspection of the soles of the foot for presence of ulcers, look at nail for signs of brittlity, between the toes for fungal infections. Proceed to the dorsal surface of the foot, noting whether or not the foot is pale.

Proceed to the calf note for diabetic dermopathy e.g. necrobiosis lipoidica diabeticorum, hyperpigmentation, signs of cellulitis, loss of hair and shiny skin. At the knee, look for deformities of the knee joint such as charcot joints. Up at the thigh, look for signs of quadriceps femoris muscle wasting which is a result of diabetic amyotrophy. Also look for insulin injection sites.

Palpate the foot for temperature noting the part that feels cold. Feel the pulses. If dorsalis pedis absent, proceed with capillary refilling time. Palpate the knees for charcot joints. Palpate for lipodystrophy in the injection sites. Always ask patient for tenderness b4 palpating.

Next, examine the sensory perception. Using an orange stick, prick the plantar surface at 4 points. Go upward until patient can feel. NEVER prick an ulcer. No need to test soft sensation. When u r presenting, present in " Sensation is lost up to mid calf". No need for dermatomes because diabetic neuropathy affect any vulnerable nerve endings. Sometimes, in a same dermatome, there will be 1 part which can sense and 1 part which cannot.

Do proprioception and say that u would like to test vibration if a tuning fork is present.

Test for the strength of the quadriceps femoris and proximal muscles.

Next, elicit the reflexes in particular the ankle jerk. Ankle jerk will be absent in advanced diabetes.

Complete the examination by examining the upper limb, including nail candidiasis. Say that u would check for postural hypotension which is due to autonomic neuropathy in diabetes.

IF you notice any difference between my method and the lecturer, PLEASE follow the lecturer. This acts as a guide to all in medicine so that none will stare blankly when asked to examine a diabetic lower limb. All the best, Merry Christmas and Happy wonderful 2009!

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