ASSESSMENT OF DIABETIC FOOT & COMPLICATIONS

LABEL THE PARTS BEFORE ANYTHING PLEASE HUHU

PERIPHERAL NEUROPATHY

1. What are the 3 subclass of peripheral neuropathy?

2. In polyneuropathy, distal or proximal loss of sensation happens first?
3. What are the 3 sensory symptoms? 3m
4. What happens to the gait , muscle?

Polyneuropathy Mononeuropathy
Limb involvement :
symmetry / X?
Distal or proximal 1st
Example conditions

CHARCOT'S FOOT

5. What are the other 2 place charcot deformity occurs other than foot and ankle? 2m
6. What is the pathophysiology? 5m (chronic hyperglycemia --> sorbitol, fructose --> schwann
cell --> neuropathy --> sensory, neurotrauma, neurovascular --> high arch, clawing... etc)
Involvement of motor nerves to the small muscles of the feet gives rise to interosseous wasting. Unbalanced traction by the long
flexor muscles leads to a characteristic shape of the foot, with a high arch and clawing of the toes, which in turn leads to abnormal
distribution of pressure on walking, resulting in callus formation under the first metatarsal head or on the tips of the toes and
perforating neuropathic ulceration. Neuropathic arthropathy (Charcot’s joints) may sometimes develop in the ankle.
7. What 2 complications occurs after charcot deformity? 2m
8. How plantar ulceration occurs? 2m
 9. What are the 3 early clinical signs?

Sx Answer
Vibration
Pain Sensation
Proprioception
Temperature
Numbness : symmetry/ asym?
Inspection : Swelling? Redness?
Skin changes? Pain?
Motor changes; deformity? What
happens to medial arch?
Monofilament testing

10. Which pain sensation loss first, deep or superficial?

11. List 4 x-ray findings you will see in both early and late changes?
12. What is the 1st line (non-operative) management?
13. What are the operative surgery? What is the difference between two? 2m
14. List 2 post-op care. 2m
15. So then when is amputation indicated? 2m

DIABETIC FOOT ULCER

1. What is the pathophysiology based on neuropathy (sensory, motor, autonomic), PAD?

6m
2. What is the 3 subtypes?
3. Fill up the blank space

Neuropathic Ischemic Neuro-ischemic

Site
Sensation
Callus/Necrosis
Wound describtion
(pin,pale,
granulation?)
Foot T, pulse
Findings : Dry skin,
Fissure, Delayed
healing?

4. What are the hx you need to obtain? Framework pls?

 5. What are the PE findings?
6. What is the Grading used? How you treat according to grading?
7. What is another classification used? Sinbad
8. Describe and Grade the wounds. Give appropriate mx.

9. Outline management [first line (non-op), op)]

10. What is the absolute contraindication for total contact casting?
11. Which grade is indicated for surgical debridement?
12. What is Syme, Chopart, Lisfranc, transmetatarsal amputation?
13. What are the bedside examination and Ix to order?
14. What is the associated cx? What is the common organism?

DFU COMPLICATIONS
WOUND INFECTION

1. What are the physical findings of infected wound? 3m

2. What are the extrinsic and intrinsic factor causing delayed wound healing?
3. The Infectious Diseases Society of America (IDSA) and the International Working Group
on the Diabetic Foot (IWGDF) grading :

Grading Findings ( Sx? Structures? Extension?)

Uninfected
Mild
Mod
Severe

4. a) Based on the grading, what are the criterias suggesting local infection? 5m
 b) When/how you define as local infection? 2m
5. What are criteria of SIRS? Min num of criteria should fit in to define SIR? 4m
6. So then what about Sepsis, Severe Sepsis, Septic Shock?

FOOT GANGRENE
1. Definition of gangrene? Is it a must to have bacterial invasion? 3m
2. List 3 causes.
3. List 3 types of gangrene. Which one is common in DM?
4. Gas gangrene
b) What is the commonest organism causes gas gangrene?
C)Where is the commonest site?
d) Pathophysiology of gas gangrene. 3m
e) What is the clinical triad?
f) Give 5 PE findings of foot.
g) Patient is having altered mental status. What are you worried of?
h) Fill up the Ix findings

Ix Findings
FBC
LDH
pH, HCO3
Renal Profile
Histology 1)Hallmark?
2)
C&S
X-ray
i) What is the 2 non-surgical therapy?
j) What is the 1st line a/biotic?
h) How hyperbaric Oxygen therapy works?
i) What is the 2 surgical managements?

NECROTISING FASCITIS

65 y/o chinese lady, p/w limb swelling 3 months prior to admission

swelling @ shin, painless, 2X2 cm --> grow 10 X 5 cm --> pus & discoloration

PMH
 DM , oral anti-diabetics 15 yrs
 HPT
PE
 15 X 10, reddish blackish discoloration
 3 skin bullae2 X 2 cm

Ix : WBC high , ESR, CRP high, RP : Creat, Urea hgh, RBC : High, HBA1c: High,
X- ray : ST shadowing

Discussion questions?
1. What is your ddx?
2. What is the PE findings for gas gangrene vs cellulitis?
3. What is the plan of mx ? Emergency radical debridement
4. In cellulitis tissue viable/ x? What about NF gangrene? How management differs?
5. How patient with septic shock presents?
6. How you manage septic shock patients?
- resucitate, IV fluid
- cvp line : to measure ? intravascular volume depletion (peripheral vasodilation)
- so if give IV fluid still bp tk naik , cvp tknaik --> give dopamine
- pt ada HHS : IV insulin ( 15 U actrapid + 15 unit NS) --> monitor hrly , electrolyte
correction

7. What is the common organism causing NF? GA Beta hemolytic. What are the
appropriate a/biotics? 3rd gen cephalosporin, augmentin, unasyn + metronidazole
8. When we inspect wound after debridement?
9. What type of wound is NF?
10. If open # what is the common org? Stp.A, cloxacilin

1. What are the compartments involved? 2m

2. What are the 4 types of organism causing each type of NF? 4m
Clue : Polymicrobial, mono, marine bacteria, fungal
3. Which type common in extremities?
4. Pathophysio pls. 2m
5. What are the early vs late clinal signs. 4m
6. What are the findings

Overlying skin changes?

Erythema?
Swelling? Bullae (yes/no?)
Discoloration
Subcutaneous changes?

7. What is 1 important ddx? 1m

 8. For ix, X-ray needed?
9. Then what ix needed for dx?
10. What is the scoring used? How much score indicates NF?

0 1 2 4
CRP
Hb
Total Leukocyte
Serum Na
Serum Cr
BG

11. What are the important operative findings? 3m dishwater pus, necrosed
muscle,liquified sc fat
12. What are the principle of mx? 3m
13. What is the empirical a/biotic choice?
14. What are the definitive antibiotics for organisms?

Strep/ Clostridium Pen G

Polymicrobial Imipenem
MRSA Vanco

15. If anaerobe, what can be used?

CELLULITIS
1. Which layers are affected? 2m
2. What are the 2 common organisms? 2m
3. Give 2 risk factor other than diabetes
4. Pathophysio please. 2m
5. Explain the findings
6. Give clinical mx & PE findings.
7. What is the principle of management? 4m