Diabetic Foot Consultations

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With continuing diabetic foot consultations we always:
palpate pedal pulses
check nerves with a monofilament
perform general treatment

I have accepted this as routine. But why do we need to check pulses and nerves every consultation? Does it change your treatment plan? Would you inform the GP if there is a change?

I can see the benefit on an initial consultation and annual consultation.

If one day your unable to palpate Dorsalis Pedis on a winters morning, what would you do?

 

There was some great discussion about this over at Diabetic Limb Salvage Conference recently in Washington DC.

Basically they were asking the same question - if it doesn't or will not change management why do you routinely do it? Discussions then shifted to simple monitoring and routine screening. The concept being that it is a chart measure (similar to monitoring BP and respiration whilst under general anaesthesia). Over time the chart/graph can be viewed and issues can be identified. To me this makes the most sense.

Also routinely in the US it is done by nurses/foot care assistants before the Podiatrist even enters the consultation.

The suggestions for routine Podiatric screening was discussed and consensus was a minimum upon every consultation should be:

Palpation of Pulses
Monofilament
Calibrated tuning fork
Portable Doppler

I think this is sensible and if charted correctly provides valuable long term data for patient monitoring and sharing between professionals. Personally I do this for every patient purely as a way of monitoring progress.

 

I see no added benefit in doing a neurovascular assessment at every consultation (assuming they are presenting for episodic skin and nail care).

After caring for ?1000's of diabetic feet, I am yet to see anything more than mild to moderate variations in the nature and severity of degenerative neuropathy or PAD from year to year. However once established, the sequelae of these issues can naturally occur rapidly and without warning.

Hence, where there is no established diagnosis is in place for DPN or PAD, I feel little is to be gained from anthything other than annual screening.

BTW - if you can palpate a pulse, and note reasonable capillary fill times in the absence of claudiction and other risk factors - I feel there is little indication for Doppler assessment - providing you do not suspect cardiac arrythmia or other. I think the trend towards Doppler/ABI at every annual review is overkill (? exploitation of the MBS in some situations) if there is no clinical suggestion of PAD.

Just my observations,

LL

 

All fair enough points Tony - and all fair enough reasons not to routinely test.

Simply graphing or charting progress I feel is extremely important personally and something we especially in Australia do not do as well as some of our worldwide counterparts.

Don't get me started on exploitation of MBS - I don't think Podiatrists generally have a large part to play in this. However once could argue if we are not charting progress or monitoring it routinely, then maybe we should question our role in it at all?

 

What about the patient feelings that they are getting the correct level of treatment whether the results are going to change your treatment appproach or not.

They get it rammed into them about how important footcare and foot health is, so to make them feel comfortable with treatment , a 5 min foot health review may make the patient more comfortable with their diabetic situation

 

Hi there

It depends on how often you are seeing the patient.

At a "new" patient/initial consultation I believe that you should complete the whole assessment.Obviously if the patient presnts with complications eg acute Charcot foot,ulcers etc you will have to complete the assesment and further manage the condition as you normally would.

If you see the patient regularly for routine care,I also palpate pulses whilst finding out how the patient is.With regards completing the full neurovasc assessment depends on the patients status when first assessed and what they subsequently present with and how often they are seen.

I dont think there is a magical answer-my experience working in a Diabetic woundcare clinic taught me that every patient is different and you develop a gut-feel on your patients as you get to know them.

Also,diabetic patients should be educated to take some responsibilty for their feet-they need to check their feet daily and seek necessary help if they encounter problems.Sometimes A&E is their first port of call as pods dont usually work out of office hours.

Thats my 2pence worth of thought

Regards

Faye