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Podiatry essentials the basic foot exam

Podiatry essentials the basic foot exam. Amy Splitter, DPM ACMC Division Chief, Division of Podiatry Assistant Professor, California School of Podiatric Medicine at Samuel Merritt University. Introduction. Four Basic Elements to lower extremity foot exam Vascular Neurological

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Podiatry essentials the basic foot exam

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  1. Podiatry essentials the basic foot exam Amy Splitter, DPM ACMC Division Chief, Division of Podiatry Assistant Professor, California School of Podiatric Medicine at Samuel Merritt University

  2. Introduction • Four Basic Elements to lower extremity foot exam • Vascular • Neurological • Dermatological • Musculoskeletal

  3. Vascular

  4. The vascular history • How far can you walk? • Major Risk Factors • Tobacco • Diabetes mellitus • HTN • Cardiac disease • CVA • Family history

  5. Vascular evaluation: inspection • Skin color, temp • Skin thickness and texture • Digital hair • Toenail condition

  6. Pedal Pulses • Dorsalispedis (DP) • Posterior tibial (PT) • Perforating peroneal (PP)

  7. Dorsalis pedis pulse Palpate here EHL Tendon

  8. Dorsalis pedis pulse

  9. Posterior tibial pulse Medial malleolus Palpate here

  10. Posterior tibial pulse

  11. Perforating peroneal pulse

  12. Perforating peroneal pulse

  13. Popliteal pulse

  14. Popliteal pulse

  15. Quantifying pedal pulses Absent, Diminished, Palpable, Bounding vs. 1+, 2+, 3+, 4+

  16. Capillary Refill (SPVPFT) • The time it takes to completely fill the area of pallor • Normal: < 3 seconds • PAD: > 10 sec

  17. Capillary refill technique 1. Place foot at heart level

  18. Capillary refill technique 2. Squeeze blood from the hallux

  19. Capillary refill technique

  20. Capillary refill technique 3. Observe time for blood return

  21. Capillary Refill (SPVPFT) Common Errors • Digit below heart level • Residual venous blood

  22. Doppler

  23. Doppler technique

  24. Doppler technique Apply acoustic gel

  25. Doppler Sounds Normal PT Abnormal DP Normal hallux artery Vein

  26. Artery vs. Vein

  27. Ankle Brachial Index

  28. ABI Interpretation • Ankle pressure/Brachial pressure • Normal 1.0 – 1.2 • Grossly abnormal <0.5

  29. ABI Pitfalls • Does not measure collateral flow • Cannot confirm flow distal to probe • Interpret results in diabetics with caution

  30. Neurological

  31. Common LE neurological problems • DM neuropathy • IM neuroma • Tarsal tunnel syndrome • Nerve impingement • CVA

  32. Neurological workup • PMH, ROS: Any potential causes of neuropathy? • Diabetes mellitus • Prior surgery • Nerve injury • Medications • Lower back problems • CVA

  33. Neurological workup • Personal History: Any potential causes of neuropathy? • EtOH abuse • Occupational exposures • Chemotherapy • HIV • Elderly • Many different causes

  34. Where’s the neurological problem? • Local • Regional • Sensory • Autonomic • Motor-UMN vs. LMN

  35. UMN vs. LMN Upper Motor Neuron • Affects groups of muscles • Only slight atrophy • Spasticity with hyperreflexia • No fasiculations • Normal nerve conduction studies Lower Motor Neuron • Affects individual muscles • Atrophy • Flaccidity, hypotonia and hyporeflexia • Fasiculations • Abnormal nerve conduction studies

  36. Neurological Physical Exam • Sensory examination • Motor examination • Sensory-motor examination • Gait

  37. Neuropathy Workup: Physical Exam • Compare right to left • Compare distal to proximal • Nerve injuries can be subtle

  38. Sensory Examination • Depends on the subjective response of the patient • Focus your testing based on the HPI

  39. Sensory Examination: Instruments • Safety pin • Semmes-Weinstein 10 gm monofilament • Q-tip • 128 Hz tuning fork • Paper clip

  40. Sensory Examination • Vibratory • Proprioception • Pain • Temperature • Pressure (protective sensation) • 2 point discrimination • Light touch • Percussion

  41. Sensory Examination • For each sensory test, you should consider the following: • Which nerve is being tested? • Which dermatome is being tested? • What spinal pathway is being used?

  42. Sensory Examination: Dermatomes

  43. Sensory Testing: Semmes-Weinstein Monofilament • Tests pressure sensation • Uses: • R/o LOPS • Map out sensory deficit

  44. Sensory Testing: Semmes-Weinstein Monofilament • Prerequisites • Patient understanding • Non-callused skin

  45. Sensory Testing: Semmes-Weinstein Monofilament • Prerequisites • Patient understanding • Non-callused skin

  46. Sensory Testing: Semmes-Weinstein Monofilament Demonstrate that this won’t hurt

  47. Sensory Testing: Semmes-Weinstein Monofilament Show the patient what to expect

  48. Sensory Testing: Semmes-Weinstein Monofilament Start distally

  49. Sensory Testing: Semmes-Weinstein Monofilament Bend the filament, then release

  50. Sensory Testing: Semmes-Weinstein Monofilament

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