1. DIABETIC FOOT EXAMINATION

2. Diabetic Foot Syndrome Neuropathy PVD Infection

4. Foot deformity

5. Minor trauma (were detected in more than 63% of all ulcer.) DFU : Diabetic Foot Ulcer LEA : Lower Extremity Amputation

6. 3 divisions of the PNS stocking/ glove distribution Sensory Loss Weakness Abnormal Arches Hammared Toes Motor Impairment dermal fissures xerosis Autonomic Dysfunction

7. Important for clinician to ask the following questions: Does the patient have loss of protective sensation? Is foot deformity present? Does the patient have a history of ulceration, amputation or Charcot foot?

8. Foot Inspection For : Deformity ulcers hammer toes loss of archers Charcot foot Texture of skin Integrity of skin Texture of nails Quality of subcutaneous tissue Presence of hair

9. 1- Deformity One must examine the foot for bony prominences and deformities. It is important to determine if a deformity is rigid or flexible as rigid deformities are often more difficult to accommodate conservatively and may need surgery.

11. 2- Ulcers : Wound depth: The depth of a wound is much more important for healing than the size of the wound. Wagener Gredes

12. Wound infection Wounds are considered infected if they have perulence and/or at least 2 of the following signs and symptoms: pain, warmth, erythema, oedema, lymphangitis or loss of function.

13. Ischemic Ulcer Wound ischemia can be diagnosed by the presence of necrotic tissue or gangrene within a wound, non palpable pulses or confirmatory vascular testing.

15. Charcot Foot

16. Palpation Pedal Pulse : however, the presence of palpable pulses DOES NOT absolutely exclude peripheral arterial disease.

17. Femoral Pulse

18. Popleteal

19. Buergers Elevation Test • Elevate limb until dorsal veins emptied • Plantar surface of foot turns pale (1 min.) • (If severe - ? Widespread Insufficiency)

21. Special Tests

22. Monofilament Test: The monofilament should be placed against intact skin (without callus) and allowed to buckle. The patient should have his or her eyes closed during testing and be given a forced choice i.e. asked “ Do you feel the pressure at time A or time B?”

24. Testing 10 sites (plantar to toes and metatarsal heads 1, 3 and 5, plantar midfoot medial and lateral and planter heal , 1st web space

25. The person who cannot feel at least 7 of 10 pedal sites tested is considered to have an absent protective threshold.

29. Ankle Reflex

30. The Ankle Brachial Index systolic ankle pressure systolic arm pressure ABI = The ABI is 95% sensitive and 99% specific for PAD.

31. In diabetic patient, the ABI is falsely elevated. Can assess the peripheral circulation by measuring the toe systolic pressure (normal > 40 mmHg) using either a strain gauge sensor or photoplethysmography.

33. Transcutaneous oxygen tension (normal > 40 mmHg) measurement has been used as non invasive measurement of limb perfusion.

34. Thank You