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MD4001 Neurovascular Examination Lower Limbs (in the context of diabetes)

Learning Outcomes:
demonstrate competency in performing a neurovascular examination of the lower limbs
recognise common clinical signs associated with diabetes
demonstrate fluency in presenting and summarising findings of examination

Summary Diabetic examination lower limbs

1. INTRODUCTION
A. Ensure adequate hygiene of hands
B. Introduce self and confirm patients identity
C. Explain procedure and obtain verbal permission to examine
D Ask if patient in any pain or discomfort
E. Position patient at 45 with legs and feet fully exposed

2. GENERAL INSPECTION
A. General inspection of patient and surrounding area: BMI, respiration, ketones, dehydration

3. ASSESSMENT Pulse and BP

A. Rate and rhythm at radial pulse (autonomic neuropathy)
B. Measure BP now or at end of examination. Lying and standing if indicated (postural hypotension)

4. INSPECTION of lower limbs

A. Colour: pallor, cyanosis, redness
B. Skin: hair loss, dry, eczema, atrophic shiny skin, pustules, abscesses, infections, including fungal
infections nails and between toes
C. Deformity: neuropathic joints (Charcot joints due to loss of proprioception)
D. Ulcers: legs, between toes and pressure points. Necrotic and missing toes.
E. Calluses: incorrectly fitting shoes?

5. PALPATION of Lower Limbs

A. Assess temperature of limbs the legs running back of hand from toes towards groin, (both limbs
simultaneously to compare warmth.)
B. Check capillary refill time in the feet
C. Assess pulses both limbs: dorsalis pedis, posterior tibial, popliteal
D. Fine touch: Monofilament 10-g: in at least 5 areas across the foot, ensuring test same areas on
each foot. (toes, metatarsal heads)
E. Sharp / Dull Sensation: use neurotip
F. Vibration Sense at great toe: if vibration sense intact at toes no need to check further
G. Proprioception: ensure hold sides of great toe, avoiding the nail-bed

6. REFLEXES
A. Ankle reflexes: loss early sign of peripheral sensory neuropathy

7. ASSESSMENT OF GAIT
A. Smoothness and symmetry. Look for foot drop, broad based gait, antalgic gait (may suggest
Charcot neuroarthropathy)
B. Turning: - quick, slow, poor balance, staggered
C. Examine shoes: pattern of wear on soles, e.g. asymmetrical wearing, incorrect size, holes

8. Other: Eyes
A. Assess for dyslipidaemia and perform ophthalmoscopy for diabetic retinopathy
B. Look at observation charts, urinalysis for glucose and nitrites. Capillary blood glucose.

9. CONCLUSION
A. Thank patient and ensure appropriate hand hygiene
B. Summarise, and present findings orally and in patients notes