3 Minute Rapid Diabetic Foot Examination

3 Minute Rapid Diabetic Foot Examination Risk Stratification Primary Care Providers Non-specialist Referral guidelines
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  646 THE JOURNAL OF FAMILY PRACTICE | NOVEMBER 2014 | VOL 63, NO 11 Te 3-minute diabetic foot exam Early detection of diabetes-related foot problems can be lifesaving. Tis brief exam will help you to quickly detect major risks and prompt you to refer patients to appropriate specialists. F oot ulcers and other lower-limb complications sec-ondary to diabetes are common, complex, costly, and associated with increased morbidity and mortality. 1-6  Unfortunately, patients often have difficulty recognizing the heightened risk status that accompanies the diagnosis of dia-betes, particularly the substantial risk for lower limb compli-cations. 7  In addition, loss of protective sensation (LOPS) can render patients unable to recognize damage to their lower extremities, thus creating a cycle of tissue damage and other foot complications. Strong evidence suggests that consistent provision of foot-care services and preventive care can re-duce amputations among patients with diabetes. 7-9  However, routine foot examination and rapid risk stratification is often difficult to incorporate into busy primary care settings. Data suggest that the diabetic foot is adequately evaluated only 12% to 20% of the time. 10   In response to the need for more consistent foot exams, an American Diabetes Association (ADA) task force lead by 2 of the authors of this article (AB and DA) created the Compre-hensive Foot Examination and Risk Assessment. 5 Tis set the standard for the detailed investigation of lower limb pathol-ogy by a specialist, but was not well suited for other practice settings, including primary care. One reason is that it would be difficult to complete the comprehensive examination dur-ing a typical 15-minute primary care office visit. In addition, certain examination parameters   require the use of neurologic and vascular assessment equipment and training not avail-able in all health care settings. 11   With these thoughts in mind, we set out to develop an exam that could be done by a wide range of health care pro- viders—one that takes substantially less time to complete than a comprehensive exam and eliminates common barri-ers to frequent assessment. Te exam, which we’ll describe here, consists of 3 components: taking a patient history, performing a physical exam, and providing patient edu- John D. Miller, BS; Elizabeth Carter, BS; Jonathan Shih, BS; Nicholas A. Giovinco, DPM; Andrew J.M. Boulton, MD; Joseph L. Mills, MD; David G. Armstrong, DPM, MD, PhD The Southern Arizona Limb Salvage Alliance (SALSA), University of Arizona College of Medicine, Tucson (Mr. Miller and Shih, Ms. Carter, and Drs. Giovinco, Mills, and Armstrong); Center for Endocrinology and Diabetes, Faculty of Health Sciences, University of Manchester, United Kingdom (Dr. Boulton) The authors reported no  potential conflict of interest relevant to this article. PRACTICE RECOMMENDATIONS ›   Screen for lower extrem-ity complications at every visit for all patients with a suspected or confirmed diagnosis of diabetes. A ›   Consider implementing a risk-based referral system to connect primary screen-ing with specialist care. A Strength of recommendation (SOR)   Good-quality patient-oriented evidence Inconsistent or limited-quality patient-oriented evidence Consensus, usual practice, opinion, disease-oriented evidence, case series ABC What is the biggest obstacle to making foot exams a routine part of office visits with patients who have diabetes? n   Lack of time n   Lack of special-ized equipment (eg, vibratory per-ception threshold device, Semmes-Weinstein monofilament) n   Need to focus on urgent clinical concerns n   There are no obstacles. It is a routine part of these visits. INSTANT POLL  647 JFPONLINE.COMVOL 63, NO 11 | NOVEMBER 2014 | THE JOURNAL OF FAMILY PRACTICE I  MA GE  © J   OE  G OR MAN This exam takes substantially less time to complete than a comprehensive exam and eliminates common barriers to frequent assessment. that contribute to peripheral artery disease (PAD). 13   Physical examination (1 minute) Careful inspection of the feet should be per-formed at every visit for patients with con-firmed or suspected diabetes. Because up to 50% of patients with significant sensory loss due to neuropathy may be completely as- ymptomatic, 14  failing to search for early signs of infection ( FIGURE 1 ), skin breakdown, ulcer formation ( FIGURE 2 ), skin temperature chang-es, and inadequate vascular perfusion may allow complications to develop. 5   TABLE 2 5,15,16 outlines the essential components—derma-tologic, neurologic, musculoskeletal, and vas-cular—of a rapid lower limb physical exam. z   The dermatologic exam.   Tis   serves as a barometer for early intervention, and often results in a limb-saving referral to a special-ist. It should begin with a global inspection for discolorations, calluses, wounds, fissures, macerations, nail dystrophy, or paronychia. 5  Skin discoloration or loss of hair growth may be the first signs of vascular insufficiency,  while calluses and hypertrophic skin often cation.    And best of all, it should only take 3 minutes. The patient history (1 minute) Patients may present with concerns about their feet, but may not be able to differentiate between benign and threatening symptoms.  A thorough medical history can identify fac-tors that may increase patients’ risk of devel-oping lower-limb complications.   Reviewing the patient’s medical history also can help guide the physical exam.Review the patient’s diabetic history, blood glucose control, and previous diabetic complications. Ask patients about their his-tory of peripheral vascular disease, quality of peripheral protective sensation, and previ-ous lower-limb interventions and operations ( TABLE 1 5,12 ). Patients with diabetes and sub-optimal glycemic control have an increased risk for LOPS, chronic and recalcitrant ul-cers, and wound infections. 2  Additionally, patients with diabetes and a previous lower extremity amputation are at high risk for re-ulceration. 5,12  Lastly, nicotine use and smok-ing are common pathogenic risk factors  648 THE JOURNAL OF FAMILY PRACTICE | NOVEMBER 2014 | VOL 63, NO 11 are precursors to ulcers. 5,17-19  Inspection of the toes should include a search for fungal, ingrown, or elongated nails. Carefully exam-ine the areas between the toes, where deeper lesions may go unnoticed. 5   z   The neurologic exam.  Without protec-tive sensation, patients with neuropathy are at a heightened risk of unrecognized injury and are unlikely to mention their deformi-ties to medical staff. 20-23  Consequently, skin deterioration may unknowingly progress to ulceration that requires extensive medical in-tervention or amputation. Neuropathic LOPS is easily detectable, yet Carefully exam-ine the areas between the toes, where deeper lesions may go unnoticed. TABLE 1  What to ask (1 minute) 5,12 Does the patient have a history of: ã rvis l/ft lr r lwr limb amtati/srryã rir ailasty, stt r l byass srryã ft wd rqiri mr tha 3 wks t halã smki r iti sã diabts (if ys, what ar th atit’s rrt trl masrs?) Does the patient have: ã bri r tili i ls r ftã l r ft ai with ativity r at rstã has i ski lr, r ski lsisã lss f lwr xtrmity ssati Has the patient established regular foot specialist care? TABLE 2  What to look for (1 minute) 5,15,16 Dermatologic exam: ã Ds th atit hav dislrd, irw, r latd ails?ã Ar thr sis f fal ifti?ã Ds th atit hav dislrd ad/r hyrtrhi ski lsis, allss, r rs?ã Ds th atit hav  wds r ssrs?ã Ds th atit hav itrdiital marati? Neurologic exam: ã Is th atit rssiv t th Iswih Th Tst? Musculoskeletal exam: ã Ds th atit hav fll ra f mti f th jits?ã Ds th atit hav bvis dfrmitis? If ys, fr hw l?ã Is th midft ht, rd r iamd? Vascular exam: ã Is th hair rwth  th ft drsm r lwr limb drasd?ã Ar th drsalis dis ad strir tibial lss alabl?ã Is thr a tmratr diffr btw th alvs ad ft, r btw th lft ad riht ft?  DIABETIC FOOT EXAM 649 JFPONLINE.COMVOL 63, NO 11 | NOVEMBER 2014 | THE JOURNAL OF FAMILY PRACTICE it is linked to at least 75% of all nontraumatic diabetic amputations. 20-23  A diminished vibra-tory perception threshold (VP) is one of the conTInueD on pAge 653 TABLE 3  What to teach (1 minute) 5,15,45 Recommendations for daily foot care: ã Visally xami bth ft, ildi sls ad btw ts.ã K ft dry by rlarly hai shs ad sks; dry ft aftr baths r xris.ã Rrt ay w lsis, dislratis, r swlli t a halth ar rfssial. Education regarding shoes: ã edat th atit  th risks f walki barft, v wh idrs.ã Rmmd arriat ftwar ad advis aaist shs that ar t small, tiht, r rb aaist a artilar ara f th ft.ã Sst yarly rlamt f shs—mr frqtly if thy xhibit hih war. Overall health risk management: ã Rmmd smki ssati (if aliabl).ã Rmmd arriat lymi trl. earliest indicators of neuropathic LOPS and is the best predictor of long-term lower extremity complications. 1,24,25  However, VP devices are TABLE 4 ime for a specialist? Mapping out a treatment and follow-up plan* 5 prirityIdiatisTimliSstd fllw- urt (ativ athly)o wd r lrativ ara, with r witht sis f iftinw rathi ai r ai at rstSis f ativ chart dfrmity (rd, ht, swll midft r akl)Vaslar mrmis (sdd abs f Dp/pT lss r ar)Immdiat rfrral/sltAs dtrmid by sialistHih (ADA risk atry 3) prs f diabts with a rvis histry f lr r lwr xtrmity amtatichri vs isfiy (ski lr ha, r tmratr diffr)Immdiat, r “xt availabl” tatit rfrralevry 1-2 mthsMdrat (ADA risk atry 2)prihral artry disas +/- LopSDp/pT lss dimiishd r abstprs f swlli r dmaRfrral withi 1-3 wks (if t alrady rivi rlar ar)evry 2-3 mthsLw (ADA risk atry 1)LopS +/- lstadi, hai dfrmity.patit rqirs rsritiv r ammdativ ftwar.Rfrral withi 1 mthevry 4-6 mthsVry lw (ADA risk atry 0)n LopS r rihral artry disas. patit sks dati rardi: ft ar, athlti traii, a-rriat ftwar, rvti ijry, t.Rfrral withi 1-3 mthsAally at miimm ADA, Amria Diabts Assiati; Dp, drsalis dis; LopS, lss f rttiv ssati; pT, strir tibial.*All atits with diabts shld b s at last  a yar by a ft sialist.
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