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ARIMGSAS
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Case 1: Your next patient is a middle aged woman, Mrs. Baker, who has suffered
from mature onset diabetes mellitus for 10 years which has been poorly controlled,
recent HbA1c was 11, and it was decided to start her on insulin.
* Your task is: to examine her lower limbs and to discuss your findings with the
examiner.
What implements do you require for this examination?
* Cotton wool balls
* Neurology pin
* Microfilament
* Tuning fork (128 Hz, not 256 Hz which you use for hearing tests)
* Reflex hammer
WIPER:
*Ask patient to walk looking for gait and normal phases of gait  high-
stepping gait (indicates loss of proprioception or joint position sense)
*Examine footwear
*Inspection: Inspect legs & feet thoroughly, lifting legs up to see
underneath & ensuring to look between toes.
* Colour – pallor / cyanosis /erythema (e.g. cellulitis / ischaemia)
* Dry / shiny / hair loss – peripheral vascular disease
* Eczema / haemosiderin staining – venous disease
* Ulcers – inspect between toes / heels / underneath legs
* Venous ulcers – moderate to no pain – larger /shallow – associated with venous insufficiency / varicose
veins
* Arterial ulcers – very painful – deep punched out appearance – associated with diabetes mellitus /
peripheral vascular disease
 * Swelling: Oedema – – e.g. venous insufficiency / heart failure, Deep vein
thrombosis – tender on palpation.
* Calluses – may indicate incorrectly fitting shoes
* Venous filling – guttering of veins / reduced visibility suggests PVD
* Deformity caused by neuropathy (e.g. Charcot arthropathy), hammer toes (proximal
phalanx is flexed); mallet toe (DIP is flexed) (PHMD); toe clawing (flexion of both DIP
and PIP), hallux valgus, bunions, tinea.
* Needle marks and fat hypertrophy/atrophy, wasting (especially quadriceps).
* Nails (thickening, ingrown toe nail, change of color, cyanosis), toes (cracks, ulcers).
* Gangrene: advanced macro vascular problems (“pulseless foot) or peripheral
neuropathy problem (“painless foot”). It can also be due to micro vascular changes
where pulses are still palpable! The tissue becomes necrotic with black skin either dry
or moist!
*Infection: superficial infections are common, e.g. boils, cellulitis and
fungal infections (tinea pedis) (due to ischaemia and high tissue glucose
providing ideal environment for bacterial growth).
Charcot Joint- Deformed joint
*Palpation: CRT, temperature, edema, pulse
*Neurologic examination: Test sensation at levels not
dermatome
*Light touch with cotton wool
*Pain sensation with pin prick
*Monofilament (Semmes Weinstein 10 monofilament): When the
filament bends, its tip is exerting a pressure of 10 grams. If the patient
cannot feel the monofilament at certain specified sites on the foot,
he/she has lost enough sensation to be at risk of developing a
neuropathic ulcer. Usually at 5 points on each sole of foot. Provide an
example of monofilament sensation on the patient’s arm / sternum.
With the patient’s eyes closed, place monofilament on the hallux &
metatarsal heads (1/2/3/5). Press firmly so that the filament bends.
Hold the monofilament against the skin for 1-2 seconds – ask patient to
say when they feel it. Avoid calluses / scars, as the patient will have
reduced sensation in these areas.
*Vibration (toe > medial/lateral malleolus > knee >
ASIS)
*Ask patient to close their eyes. Tap a 128 Hz tuning fork.
Place onto patient’s sternum & confirm patient can feel it
buzzing.
*Ask patient to tell you when they can feel it on their foot &
to tell you when it stops buzzing.
*Place onto the distal phalanx of the great toe on each leg in
turn. If sensation is impaired, continue to assess more
proximally – e.g. proximal phalanx.
*Proprioception.
*Power, Tone and reflexes
Diabetic Foot care
*I think you have developed a condition called diabetic neuropathy i.e. a
condition in which nerves in your foot are not able to sense the sensation
and pressure. I will refer you to specialist for the management.
*Keep diabetes under good control and do not smoke. Check feet daily
(sores, infection or unusual signs).
*Wash feet daily with lukewarm water, dry thoroughly especially toes and
soften dry skin especially around the heels; applying methylated spirits
between toes to help stop dampness
*Attend to toenails regularly (clip straight across with clippers, do not
cut them deep into corners or too short across, file any rough edge).
*Wear clean cotton or wool socks daily. Exercise your feet each day to
help circulation. Check insides of shoes to make sure no nails are pointing
into the soles.
*Annual foot examination in doctor’s office.